Child/adolescent Psychiatric Service Form Page 3
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4When do these behaviors tend to happen? _______________________________________________________
__________________________________________________________________________________________
*When was the last time these behaviors occurred? _________________________________________________
__________________________________________________________________________________________
Do these behaviors occur in the school? _________________________________________________________
_____________________________________________________________________________________
*Is the school involved in current treatment plan? Describe coordination with the school. ___________________
__________________________________________________________________________________________
Is the member involved with Special Education? ____________________________________________________
__________________________________________________________________________________________
Do these behaviors occur in the home? __________________________________________________________
__________________________________________________________________________________________
*Have family sessions occurred as often as necessary? _______________________________________________
__________________________________________________________________________________________
Do the behaviors occur in the community? ________________________________________________________
__________________________________________________________________________________________
*Legal/social service involvement? ______________________________________________________________
__________________________________________________________________________________________
*Baseline (for concurrent review, describe movement toward baseline): __________________________________
__________________________________________________________________________________________
*DSM 5 Diagnoses (Mental Health and Medical)-DSM:
Primary DX: _____________________________________________________________________________
Comorbidities: ___________________________________________________________________________
*Urine Drug Screen (UDS) & Blood Alcohol level (BAL) results:__________________________________________
__________________________________________________________________________________________
Treatment history: ___________________________________________________________________________
__________________________________________________________________________________________
This facsimile contains privileged and confidential information intended only for the use of the specific individual or entity named above. If you or
your employer are not the intended recipient of this facsimile (or an agent responsible for delivering it to the intended recipient), you are hereby
notified that, any unauthorized distribution or copying of this facsimile for the information contained in it, is strictly prohibited. If you have received
this facsimile in error, please immediately notify the person named above by telephone and return the original facsimile to the above address via
the U.S. Postal Service. Thank You.
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