ALL SERVICES WILL BE VIRTUAL UNTIL FURTHER NOTICE. Sessions will be done by video or phone until our return to the office. We do not anticipate returning to the office before 2021. Please enable JavaScript in your browser to complete this form.Child informationPlease enter the following information about the child. Name *FirstMiddleLastSocial Security NumberDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSexMaleFemaleOther/Prefer not to sayPrimary Insurance CompanyMember ID Group Number or NameWhose insurance policy is this? Is the child covered by an additional Insurance company?YesNoNot sureSecondary Insurance CompanyMember IDGroup number or nameWhose insurance policy is this? School GradeName of Teacher or Guidance CounselorDo we have permission to speak with your child's teacher or guidance counselor?YesNoN/A Do you and/or your child actively practice religion?YesNoSomewhatPrefer not to sayHas your child ever recieved psychiatric care before?NoYesUnsure/otherIf yes, briefly explain the reason for treatmentParent and Family InformationParent 1 *FirstMiddleLastDate of BirthMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeParent 2 *FirstLastDate of Birth MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAre there established custody agreements for the child? *YesNoPendingAre the arrangements ordered or approved by the court?YesNoN/AWhich parent has legal custody of the child? *Parent 1 (above) has exclusive custodyParent 2 (above) has exclusive custodyParents 1 and 2 (above) equally share custody or are one householdNeither parent listed above has custody. Another party (named below) has custody FirstMiddleLastWhich parent has the legal right to make medical decsions on behalf of the child? *Parent 1 (above) has exclusive rights to medical decisionsParent 2 (above) has exclusive rights to medical decisionsParents 1 and 2 (above) equally share rights to medical decisionsNeither parent listed above has this right. Another party (named below) has rights to medical decisions (copy) *FirstMiddleLastPlease list family members and all others in child's primary home:Please list any health conditions your child is currently recieving treatment for:Please indicate the main reason you are seeking treatmentNextEarly Childhood DevelopmentPlease answer each question as completely as possible and to the best of your knowledge about your child's life from birth to approximately age 5. Describe prenatal care. Were there any illnesses?Was he or she premature?YesNoNot sure/Can't rememberWeight at birth (in pounds)Height at birth (in inches)Please describe any birth complications or problemsWas your child breast-fed ?YesNoNot sure/Can't rememberIf yes, how long was he or she breast fed?Please list any allergies your child has or has outgrownPlease describe any sleep problems or patterns What was their personality like?At what age did your child do each of the following?Sit without support?My child is not able to do this, or this does not apply0-3 months3-6 Months6-9 Months9-12 Months12-18 Months18-24 Months2-3 Years3-4 Years4-5 Years5-6 YearsCrawl?My child is not able to do this, or this does not apply0-3 months3-6 Months6-9 Months9-12 Months12-18 Months18-24 Months2-3 Years3-4 Years4-5 Years5-6 YearsWalk without holding on?My child is not able to do this, or this does not apply0-3 months3-6 Months6-9 Months9-12 Months12-18 Months18-24 Months2-3 Years3-4 Years4-5 Years5-6 YearsHelp dress themselves?My child is not able to do this, or this does not apply0-3 months3-6 Months6-9 Months9-12 Months12-18 Months18-24 Months2-3 Years3-4 Years4-5 Years5-6 YearsTie their own shoelaces?My child is not able to do this, or this does not apply0-3 months3-6 Months6-9 Months9-12 Months12-18 Months18-24 Months2-3 Years3-4 Years4-5 Years5-6 YearsButton buttons?My child is not able to do this, or this does not apply0-3 months3-6 Months6-9 Months9-12 Months12-18 Months18-24 Months2-3 Years3-4 Years4-5 Years5-6 YearsAte with a fork?My child is not able to do this, or this does not apply0-3 months3-6 Months6-9 Months9-12 Months12-18 Months18-24 Months2-3 Years3-4 Years4-5 Years5-6 YearsStayed dry all day?My child is not able to do this, or this does not apply0-3 months3-6 Months6-9 Months9-12 Months12-18 Months18-24 Months2-3 Years3-4 Years4-5 Years5-6 YearsStayed dry all night?My child is not able to do this, or this does not apply0-3 months3-6 Months6-9 Months9-12 Months12-18 Months18-24 Months2-3 Years3-4 Years4-5 Years5-6 YearsDidn't soil his or her pants?My child is not able to do this, or this does not apply0-3 months3-6 Months6-9 Months9-12 Months12-18 Months18-24 Months2-3 Years3-4 Years4-5 Years5-6 YearsSaid their first word understandable to a stranger?My child is not able to do this, or this does not apply0-3 months3-6 Months6-9 Months9-12 Months12-18 Months18-24 Months2-3 Years3-4 Years4-5 Years5-6 YearsSaid their first sentence understandable to a stranger?My child is not able to do this, or this does not apply0-3 months3-6 Months6-9 Months9-12 Months12-18 Months18-24 Months2-3 Years3-4 Years4-5 Years5-6 YearsNextSection DividerPlease check all traits positive or negative that apply to your childAffectionateArgues, “talks back,” smart-alecky, defiantBullies/intimidates, teases, inflicts pain on othersCheatsCruel to animalsConcern for othersConflicts with parentsComplainsCries easily, feelings are easily hurtDawdles, procrastinates, wastes timeDifficulties with parent’s new partnerDependent, immatureDevelopmental delaysDisrupts family activitiesDisobedient, uncooperative, refuses, noncompliant, doesn’t follow rulesDistractible, inattentive, poor concentration, daydreams, slow to respondDropping out of schoolDrug or alcohol useEating—poor manners, refuses, appetite increase or decrease, odd combinations, overeatsExercise problemsExtracurricular activities interfere with academicsFailure in schoolFearfulFighting, hitting, violent, aggressive, threatens, destructiveFire settingLacks organization, unpreparedLacks respect for authority, insults, dares, provokes, manipulatesLearning disabilityLegal difficulties—truancy, loitering, panhandling, drinking, vandalism, stealing, fighting, drug salesLikes to be alone, withdraws, isolatesLyingLow frustration tolerance, irritabilityMental retardationMoodyMute, refuses to speakNail bitingNervousNightmaresNeed for high degree of supervision at home over play/chores/scheduleObedientObesityOveractive, restless, hyperactive, out-of-seat behaviors, restlessness, fidgety, noisinessOppositional, resists, refuses, does not comply, negativismPrejudiced, bigoted, insulting, name calling, intolerantPoutsRecent move, new school, loss of friendsRelationships with siblings or friends/peers are poor—competition, fights, teasing/provoking, assaultsResponsibleRocking or other repetitive movementsRuns awaySad, unhappySelf-harming behaviors—biting or hitting self, head banging, scratching selfSpeech difficultiesSexual—sexual preoccupation, public masturbation, inappropriate sexual behaviorsShy, timidStubbornSuicide talk or attemptSwearing, foul languageTemper tantrums, ragesThumb sucking, finger sucking, hair chewingTics—involuntary rapid movements, noises, or word productionsTeased, picked on, victimized, bulliedTruant, school avoidingUnderactive, slow-moving or slow-responding, lethargicUncoordinated, accident-proneWetting or soiling the bed or clothesNextConsent for treatmentI certify that I, and/or my dependent(s), have insurance coverage and assign directly to Dr. Richard C. Blackford, PhD, PC DBA Affiliated Counseling Services all insurance benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether paid for by insurance or not. I authorize the use of my signature on all insurance submissions. The above-named entity may use my health care information and may disclose such information to the above-named Insurance Company or Companies and their agents for obtaining payment for services and determining insurance benefits or the benefits payable for related services. *Clear SignatureYour signature below indicates that you have the legal authority to consent for your child to be treated, you consent to have your child treated, you have read this agreement and agree to its terms, and also serves as an acknowledgment that you have read or received the HIPAA notice form described above. *Clear SignatureWebsiteSubmit