Registration Form

Potential Patient Information

(indicate “prefer not to disclose” as desired)

Patient’s Name: *

Pronouns Used: *

Please provide the following for Online Tracking/Outcomes Monitoring:

Patient’s Cell Number: *

Patient’s Preferred Email Address: *

Which languages are spoken in your home?

Which language are you most comfortable speaking?

Job/Occupation (if applicable) and for how long?

Are you satisfied with your current employment?

Caregiver/Guardian Information

(if applicable)

Caregiver 1 Name:

Relationship to Patient:

Occupation:

Please provide the following for Online Tracking/Outcomes Monitoring:

Caregiver 1’s Cell Number:

Caregiver 1’s Preferred Email Address:

Caregiver 2 Name:

Relationship to Patient:

Occupation:

Please provide the following for Online Tracking/Outcomes Monitoring:

Caregiver 2’s Cell Number:

Caregiver 2’s Preferred Email Address:

Marital status:

If separated, are legal proceedings in process or anticipated: (Y / N)

If divorced, what is the custody agreement?

Please provide any relevant court documents.

Choose File

List all individuals considered to be part of the family and their ages. For those who are not part of the family of origin (e.g., significant others), include the duration of the relationship.

Who lives in the patient's home?

How did you learn about Boston Child Study Center?

Please describe the nature of all the problem(s) for which the patient is seeking services:

Current Symptoms (e.g., anxiety, depression):

For each of the problems listed above please provide additional details:

When did it start (for each problem)?

How often does it happen (for each problem)?

How does it affect the patient's life?

How has the patient dealt with it so far? Which coping skills have been working?

What does the patient and/or family hope will be different by seeking help?

Educational History

Current School (if applicable):

Grade/Year:

Previous Schools:

Dates of Enrollment:

Has the patient had any special testing or tutoring? (Y / N)

If yes, please indicate and include the most recent report:

Reason for testing/tutoring:

Dates:

Outcomes/Recommendations:

Does the patient have or has the patient ever had an IEP, 504, or other accommodation plan? If yes, please describe:

Other school-related concerns:

Developmental History

If the potential patient is not your biological child, please indicate...

Patient’s birth place:

Your relationship to the patient:

Is the patient aware? (Y / N)

How long the patient has been living with you/in your care:

Does the patient currently have contact with their birth parents: (Y / N)

If yes, what is the contact agreement?

For all completing this form, if known:

Was the patient exposed to antibiotics, medications, alcohol, drugs, or tobacco in utero? (Y / N)

If yes, please indicate:

Was the patient’s gestation a full 40 weeks? (Y / N)

If not, please explain:

Were there any complications during the pregnancy (e.g., fetal distress, emergency C-section, pre-eclampsia, nuchal cord)? (Y / N)

If yes, please indicate:

Were any special services required at the time of the patient’s birth (e.g., lights for jaundice, ICU care)? (Y / N)

If yes, please indicate:

Were there any concerns/delays in feeding, sleeping, walking, talking, or motor skills? (Y / N)

If yes, please indicate:

Did the patient participate in Early Intervention services? (Y / N)

If yes, please indicate dates and reason:

Social History

Describe the patient’s social functioning as a toddler:

What concerns, if any, are there currently about the patient’s ability to socialize/get along with peers, adults, and family members?

Which important social relationships does the patient have currently?

Which social clubs or organizations does the patient belong to, if any?

How does the patient like to spend leisure time?

Does the patient belong to a religious, faith, or spiritual community?

Which other cultural groups does the patient identify with?

How does the patient celebrate culture and spirituality?

Please list notable life events the patient has experienced (e.g., moving, caregiver change in work, change of school, deaths, births, divorce):

Notable Life Event(s):

Date of Occurrence:

Patient’s Response:

Patient Mental Health History

(list all diagnoses)

Past Mental Health History:

Current Mental Health:

Has the patient been hospitalized for mental health reasons? (Y / N) If yes, please indicate below:

Dates:

Circumstances/Reason:

Hospital/Program:

Discharge Recommendations:

Has the patient received other mental health services (e.g., therapy, IOP, PHP)? (Y / N) If yes, please indicate below:

Dates:

Type of Service:

Response to Treatment:

Name/Profession of Provider:

Does the patient have a history of traumatic experiences or abuse? (Y / N)

If yes, please briefly describe/state the traumatic experience(s):

Does the patient have a history of self-injury? (Y / N)

If yes, please describe:

Does the patient have a history of suicidal behaviors/attempts? (Y / N)

If yes, please describe:

Does the patient have access to firearms? (Y / N)

Does the patient have a history of substance use? (Y / N)

If yes, please describe:

Past & Current Medications

Medication:

Dose & Frequency:

Dates Taken:

Problem Treated:

Response to Medication:

Prescriber:

Patient Medical History

(list all diagnoses)

Past Medical History:

Current:

Has the patient seen a doctor or other healthcare professional for it? If so, what recommendations or treatment were given?

Family Medical History

Are there any biological family members with medical conditions (e.g., cardiac, diabetes, cancer)? (Y / N) If yes, please describe below:

Relationship to Patient:

Medical Condition:

Treatment/Other Information:

Family Mental Health History

Are there any biological family members with mental health conditions (e.g., anxiety, depression, schizophrenia, bipolar, learning disability, autism, ADHD, eating disorder, substance abuse)? (Y / N) If yes, please describe below:

Relationship to Patient:

Mental Health Condition:

Treatment/Other Information:

Has the patient known anyone who attempted or completed suicide? (Y / N) If yes, please explain:

Has there ever been any legal history (including involvement with DCF)? (Y / N) If yes, please explain when and for what:

Registration complete! Thank you for your submission, it has been sent to our team. Once we have processed your information, we will get back to you as soon as possible.

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