Assessment - Adolescent FINAL

Child Adolescent Preliminary Assessment Form

This form should be completed by the prospective patient’s parent, guardian, or healthcare provider. We estimate it should take approximately 10 minutes to complete.

Note: This form does not indicate that you are committing to treatment.

General Information

*Required

First name of person completing this form: - Copy

First name of person completing this form:*

Last name of person completing this form:*

Your relationship to the child (Treatment Professionals, please indicate your discipline): *

Child’s legal first name:*

Child’s middle name:*

Child’s legal last name:*

Child’s date of birth:*

MM/DD/YYYY

Child’s age*

The Child’s Physical Address:

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Street 1*

Street 2

City*

State*

Zip Code*

Country*

Parent/Guardian #1 Information:

Parent/Guardian Full Name:*

Relationship to Patient:*

Phone Number:*

Email Address:*

May we communicate with this person regarding confidential information using the contact information above?*

Yes No

Does this person have/share legal custody of the patient?*

Yes No

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Street 1*

Street 2

City*

State*

Zip Code*

Country*

Parent/Guardian #2 Information:

Parent/Guardian Full Name:

Relationship to Patient:

Phone Number:

Email Address:

May we communicate with this person regarding confidential information using the contact information above?

Yes No

Does this person have/share legal custody of the patient?

Yes No

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Street 1

Street 2

City

State

Zip Code

Country

Behavioral Information

Briefly stated, why are you seeking treatment for the child at this time? *

Approximately how long has the child struggled with food, body weight, body shape, body size, or body appearance? *

Eating disorders present in a variety of different ways. Please detail the child’s eating disorder symptoms and behaviors, including restricting, binge eating, purging (by vomiting, or by laxative or diuretic use), and compulsive exercise): *

24-Hour Recall

Please indicate the past 24 hours of the child’s food and liquid intake. Include meal times, food selections, and approximate amount eating. Please also note episodes of binging, purging, exercise, and/or restricting. Please provide an answer for all questions below, even if the descriptor is "N/A".

Wake-Up Time:*

Breakfast:*

Morning Snack:*

Lunch:*

Afternoon Snack:*

Dinner:*

Evening Snack:*

Bed Time:*

During normal sleeping hours:*

Educational Setting

Does the child have an IEP (Individual Education Plan) or 504 plan?*

Yes No

If any, what individualized services or accommodations does the child receive in his/her academic setting*

Has the child ever had psychological testing completed? *

Yes No

Has the child ever been diagnosed with an Autism Spectrum Disorder?

Yes No

Behavioral Information

Please describe mood swings, impulsive behaviors, sadness/depression, anxiety, irritability, or anger: *

Has the child ever become verbally aggressive (yelling, threatening others, or “talking back” to caregivers)?*

Yes No

If yes, please explain the verbal aggression (including behavior, frequency, and outcome).*

Has the child ever become physically aggressive or violent towards other people, animals, or property (hitting, kicking, pushing, destroying property, etc.)?*

Yes No

If yes, please explain the physical aggression (including behavior, frequency, and outcome). *

Self-Harm Behaviors

To your knowledge, has the child ever attempted suicide? *

Yes No

If yes, how many times?*

Please list approximate dates and what methods were utilized:*

To your knowledge, has the child ever attempted to intentionally inflict physical harm upon themselves (cut, hit, burn, etc.)? *

Yes No

If yes, please detail (include frequency of behavior, location on body):*

Please provide the date of the last self-harming episode:

MM/DD/YYYY

To the best of your knowledge, which of the following applies to how your child currently feels:*

0 - I do not have any thoughts of killing myself. 1 - I have thoughts of killing myself, but I would not carry them out. 2 - I would like to kill myself. 3 - I would kill myself given the chance.

Please note that this form is not actively monitored. If you are experiencing thoughts about suicide or self-harm, please reach out for assistance:

If you are on-site: Please speak with a staff member (e.g. your assessor, a nurse, a TA, or a member of your treatment team)

If you are off-site: Text CONNECT to 741741 to reach trained crisis counselors at the Crisis Text Line. (https://www.crisistextline.org/textline/)

Dial 1-800-273-8255 to reach the National Suicide Prevention Lifeline. (https://suicidepreventionlifeline.org/)

If you are experiencing a medical or mental health emergency, please dial 911 to proceed to your nearest emergency room.

Acknowledgement*

Please click to acknowledge that you have read and understood the statements above.

Please describe any current or previous treatment received for the child’s eating disorder or other mental health concerns (Outpatient, IOP, Partial Hospitalization, Residential, or Inpatient), including date(s), care provider(s), length(s) of treatment, and outcome(s):*

Hospitalization

Has the child ever been hospitalized for a substance use disorder, emotional or psychiatric concerns, and/or medical problems not related to the eating disorder? *

Yes No

If yes, please detail date(s), location(s), and reason for hospitalization(s):*

Additional Information

We have a therapy dog who does on-site visits. Please note any pet allergies or concerns about working with a therapy dog:

How did you hear about Veritas Collaborative?*

Physician Clinician Dietitian School Representative Radio Website Treatment Facility

Other:

Please indicate the name(s) of your answer(s) above:

We are aware this assessment cannot fully capture your experience with an eating disorder. We encourage you to list below any additional information below you would like to convey. Feel free to attach any additional pages if necessary.

Printed name of parent(s) or legal guardian(s) completing this form: *

Signature of parent(s) or legal guardian(s) completing this form:*

[clear]

Use your mouse or finger to draw your signature above

Today's date:*

MM/DD/YYYY

Progress

Child Adolescent Preliminary Assessment Form

General Information

The Child’s Physical Address:

Parent/Guardian #1 Information:

Parent/Guardian #2 Information:

Demographic Information

Health Information

Behavioral Information

24-Hour Recall

Educational Setting

Substance Use

Behavioral Information

Self-Harm Behaviors

Hospitalization

Additional Information