outpatient therapy questionnaire Patient name Patient's date of birth Patient's gender - None -Male Female Parent/Guardian name Parent/Guardian phone number Parent/Guardian address Parent/Guardian Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Who is the legal guardian/custody agreement for patient? What school does the patient attend? What grade is the patient in? What is the patient's current diagnosis or reason for referral? Please describe any treatment the patient has tried Has the patient had outpatient counseling? Yes No If the patient has had outpatient counseling, when and where? Has the patient had medication management? Yes No if the patient has had medication management, when and where? Does the patient have a history or current Autism Spectrum Disorder (ASD) Diagnosis? Yes No If the patient has been diagnosed with ASD, when and where were they diagnosed? Does the patient have a history or current substance use disorder diagnosis? Yes No If the patient has a history or current substance use disorder, when and where were they diagnosed? Does the patient have a history or current oppositional defiance or conduct disorder diagnosis? Yes No If the patient does have a history or current oppositional defiance or conduct disorder, when and where were they diagnosed? In the past three months, has the patient made any threats or attempts to hurt self or others? Yes No If the patient has made threats or attempts to hurt themselves or others, how, when, why and what medical treatment was required? In the past three months, has the youth tried to cause or has he/she caused physical injury (including sexual) to another person or against property? Yes No If the patient has tried to cause or caused physical injury, was it a one time occurrence or multiple times? was this inside the home or outside the home? Was this person a family member, peer or an authority figure? Are there any current legal charges related to hurting others or the destruction of property? Yes No Do you have concerns that the patient may hurt others during his/her treatment? Yes No
