Rock Landing Psychological Group, PLC

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Rock Landing Psychological Group - Information Forms
Client Information Forms
Please select a form below to fill out and submit. All information will be kept strictly confidential.
  • Child/Teen Information Form
  • Adult Information Form
Child/Teen Personal Information
Name
Name you prefer to go by
Email
Marital Status
Date Of Birth
Address - Street
Address - Street 2
City
State
ZIP
Home Phone Cell Phone
Employer (or school) Work Phone
Occupation SSN
Emergency Contact Phone
Parent/Guardian (if minor)
If different than above, Guarantor Information (Responsible Party)
Relationship to Client
Guarantor Name
Guarantor Address
Guarantor Date of Birth
Sex
Employer Occupation
Home Phone Work/Other Phone
Insurance Information
Primary Insurance Effective Date
Subscriber Name Subscriber SSN
Policy ID # Group #
Subscriber's Employer Subscriber's
Work Phone
 
Secondary Insurance Effective Date
Subscriber Name Subscriber SSN
Policy ID # Group #
Subscriber's Employer Subscriber's
Work Phone
Permission To Call
We may need permission to reach you to verufy or discuss an appointment. Please indicate below how you would prefer us to contact you
I give permission to call my home and/or leave a message there.
I give permission to call my place of employment and/or leave a message there.
I prefer to be contacted at this number
Referral Information
Who referred you to this practice?
Are you currently involved in the legal system? Check all which apply:
Arrest Divorce
Child Custody Disability
DUI/DWI Lawsuit
Brief Health Information

1. List all medications you take
Medication/Drug Dose Taken For

2. List all diseases, illnesses, significant accidents and injuries, surgeries, hospitalizations, periods of loss of consciousness, seizures, and any other medical conditions you have or have had.
3. Are you now being treated for any medical condition?
If yes, name or describe condition:
4. When was your last medical exam?
5. Your health is
6. Describe any allergies you have
Allergic to: Reaction you have Allergy medications taken
Health Habits
Do you smoke cigarettes? Number of packs per day
Other tobacco products? Use per day
Do you drink alcohol? Approximate number of drinks per day (average)
How many cups of caffeinated beverages do you drink each day (coffee, tea, cola)?
Do you frequently take over-the-counter medications?
If "yes", choose the closest items below
Antihistamines Antacids Laxatives
Do you take vitamins/food supplements? If so, which ones?
Do you use street drugs? If yes, which ones?
Do you engage in any of the following?
Binge Eating Use Laxatives Self Induced Vomiting Overeating
How often do you excercise?
Mental Health History
Have you ever had a psychiatric hospitalization?  
Facility
Have you ever had mental health/family counseling?  
Have you ever been under the care of a psychiatrist?  
Have you ever thought a lot about trying to kill yourself?  
Have you ever tried to harm or kill yourself?  
Child & Teen Checklist of Characteristics
Affectionate
Argues," talks back", "smart alecky", defiant
Bullies/intimidates, teases, inflicts pain om others, bossy, picks on others
Cheats
Cruel to animals
Concern for others
Conflicts with parents over rule breaking, money, chores, homework, grades, choices in music/clothes/hair/friends
Complains
Cries easily, feelings are easily hurt
Dawdles, procrastinates, wastes time
Difficulties with parent's new partner/new marriage/new family
Dependent, immature
Developmental delays
Disrupts family activities
Disobedient, uncooperaztive, refuses, non-compliant, doesn't follow rules
Distractible, inattentive, poor concentration, daydreams, slow to respond
Dropping out of school
Drug or alcohol use
Eating - poor manners, refuses, appetite increase or decrease, odd combinations, overeats, undereats, binging, vomiting
Exercise problems
Extracurricular activities interfere with academics
Failure in school
Fearful
Fighting, hitting, violent,aggressive, hostile, threatens, destructive
Fire setting
Friendly, outgoing, social
Hypochondriac, always complains of feeling sick
Immature, "clowns around", has only younger playmates
Imaginary playmates, fantasy
Independent
Interrupts. talks out, yells
Lacks organization, unprepared
Lacks respect for authority, insults, dares, provokes, manipulates
Learning disability
Legal difficulties - truancy, loitering, drinking, vandalism, stealing, fighting, drugs
Likes to be alone, withdrawn, isloates
Lying
Low frustration tolerance, irritability
Mental retardation
Moody
Mute, refuses to speak
Nail biting
Nervous
Nightmares
Need for high degree of supervision at home over play/chores/schedule
Obedient
Obesity
Overactive, restless, fidgety, noisiness
Oppositional, resists, refuses, does not comply, negative
Prejudiced, bigoted, insulting, name calling, intolerant
Pouts
Recent move, new school, loss of friends
Relationships with sisters/brothers or friends/peers are poor - competition, fights, leasing/provoking, assaults
Responsible
Rocking or other repetitive movements
Runs away
Sad, unhappy
Self-harming behaviors - biting or hitting self, head banging, scratching self
Speech difficulties
Sexual: sexual preoccupation, public masturbation, inappropriate sexual behaviors
Shy, timid
Stubborn
Suicide talk or attempt
Swearing, foul language
Temper tantrums, rages
Thumb sucking, finger sucking, hair chewing
Tics - involuntary rapid movements, noises, word productions
Teased, picked on, victimized, bullied
Truant, school avoiding
Underactive, slow moving, lethargic
Uncoordinated, accident prone
Wetting or soiling the bed or clothes
  Any other charactetistics (fill in below)
Developmental History
At what age did your child
Sit up?
Crawl?
Walk?
Make vocal sounds?
Use first words like, "mama" or "dada"?
Put 2 words together?
Speak in multiple word sentences?
Toilet trained?
Has your child ever had any accidents resulting in injuries? (broken bones, severe cuts or bruises, stomach pumped, head injury, eye injury, lost teeth, had stiches, etc.)
Do you have any concerns about your child's current health?
Hearing Vision Speech
Gross motor coordination (walking, running, climbing) Fine motor coordination (writing, closing buttons, etc.) List any other health concerns
Does your child have bladder control problems?  
Does your child have bowel control problems?  
Has there been a history of alleged child abuse for this child's family?
(physical, sexual, and/or emotional abuse, neglect)

Have there been any family stressors within the past 12 months?
(divorce. separation, change in residence, death in family, family financial or legal difficulties)
Has your child ever been enrolled in a special education program or received any type of individualized educational services?
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Adult Personal Information
Name
Name you prefer to go by
Email
Marital Status
Date Of Birth
Address - Street
Address - Street 2
City
State
ZIP
Home Phone Cell Phone
Employer Work Phone
Occupation SSN
Emergency Contact Phone
Parent/Guardian (if minor)
If different than above, Guarantor Information (Responsible Party)
Relationship to Client
Name
Address
Date of Birth
Sex
Employer Occupation
Home Phone Work/Other Phone
Insurance Information
Primary Insurance Effective Date
Subscriber Name Subscriber SSN
Policy ID # Group #
Subscriber's Employer Subscriber's
Work Phone
 
Secondary Insurance Effective Date
Subscriber Name Subscriber SSN
Policy ID # Group #
Subscriber's Employer Subscriber's
Work Phone
Permission To Call
We may need permission to reach you to verufy or discuss an appointment. Please indicate below how you would prefer us to contact you
I give permission to call my home and/or leave a message there.
I give permission to call my place of employment and/or leave a message there.
I prefer to be contacted at this number
Referral Information
Who referred you to this practice?
May we have permission to thank them for this referral?
Have you been seen here before?
If "yes" please give the approximate date and reason for seeking counseling
Additional Information
Name of Children Age of Children
Legal Information
Are you currently involved in the legal system? Check all which apply:
Arrest Divorce
Child Custody Disability
DUI/DWI Lawsuit
Brief Health Information

1. List all medications you take
Medication/Drug Dose Taken For

2. List all diseases, illnesses, significant accidents and injuries, surgeries, hospitalizations, periods of loss of consciousness, seizures, and any other medical conditions you have or have had.
3. Are you now being treated for any medical condition?
If yes, name or describe condition:
4. When was your last medical exam?
5. Your health is
6. Describe any allergies you have
Allergic to: Reaction you have Allergy medications taken
7. Have you done any kinds of work during which you were exposed to toxic chemicals?
Date Chemicals Kind of Work Effects
 
Health Habits
Do you smoke cigarettes? Number of packs per day
Other tobacco products? Use per day
Do you drink alcohol? Approximate number of drinks per day (average)
How many cups of caffeinated beverages do you drink each day (coffee, tea, cola)?
Do you frequently take over-the-counter medications?
If "yes", choose the closest items below
Antihistamines Antacids Laxatives
Do you take vitamins/food supplements? If so, which ones?
Do you use street drugs? If yes, which ones?
Do you engage in any of the following?
Binge Eating Use Laxatives Self Induced Vomiting Overeating
How often do you excercise?
Mental Health History
Have you ever had a psychiatric hospitalization?  
Facility
Have you had mental health/family/marriage counseling?  
Have you ever been under the care of a psychiatrist?  
Have you ever thought a lot about trying to kill yourself?  
Have you ever tried to harm or kill yourself?  
Adult Checklist of Characteristics
Please check all of the items that apply, and add any others at the bottom of the checklist under
"Additional Concerns or Issues"
Mood
Anger, hostility, arguing, irritability Loss of control, outbursts
Aggression, violence Inferiority
Nevousness, panic/anxiety attacks

Loneliness
Crying spells Low self esteem
Depression, low mood, sadness

Mood swings
Emptiness Nervousness, tension
Failure Pessimism
Fatugue, tiredness, low energy Shyness
Fear, phobias Stress, tension
Grieving deaths, losses, divorce Suspiciousness
Guilt

Withdrawal, isolating
       
Relationship Problems
Children, child care, parenting Family conflict
Childhood issues (own childhood) Friendships
Child custody/visitation Interpersonal conflicts
Dependence Divorce/separation
Marital conflict/infidelity/affairs Sexual issues, disfunction, desire differences
       
Substance Abuse Problems
Alcohol abuse/dependency Smoking and tobacco use
Smoking and tobacco use Street drugs
Prescription medications    
       
Health Problems & Concerns
Overeating Menstrual problems
Undereating/food restriction PMS
Binging Menopause
Vomiting Self neglect, poor self care
Illness/injury Sleep too much
Medical concerns Sleep too little
Physical problems Insomnia
Headaches Nightmares
       
Problems with Thinking

Attention, concentration, distractability

Decisionmaking, indecesion, putting off decisions

Obcession, compulsions, thoughts/actions that repeat

Delusions (false ideas)

Memory problems

Confusion
       
Abuse
Physical Neglect (of child or elderly)
Sexual Cruelty to animals
Emotional    
       
Employment/Career Problems
Career goals Problems with co-workers
Career choices Unemployment
Over working Can't keep a job
       
Financial/Legal Problems
Bankruptcy Gambling
Consumer debt Arrest
Impulsive spending Lawsuit
Low income DWI/DUI
       
Other Problems
Oversensitivity to rejection Low motivation, laziness
Perfectionism Judgement problems, risk taking
Procrastination Irresponsibility
Self centeredness    
       
Additional Concerns or Issues
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Rock Landing Psychological Group, PLC
The James Building 11825 Rock Landing Drive Newport News, VA 23606 Phone: (757) 873-1736 Fax: (757) 873-1028
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