Child Basic Psychological Evaluation

Name of Patient:*
Date of Birth*
Date Format: MM slash DD slash YYYY
Name of Person Completing Form:*
Contact Information of Person Completing Form:
Phone*
Email*
Referring Agency:*
Medicaid Number:
Social Security Number:
If not Medicaid or CMO, Agency Responsible for Payment:
Date Written Report is Needed:*
Date Format: MM slash DD slash YYYY
Why is this child involved with your agency/DFCS? (Please be specific and include dates if applicable)*
Indicate where the child is currently placed and note any specific emotional/behavioral/developmental issues of concern related to psychological functioning:*
Is there any substantiated or suspected abuse of this child?*
What school does this child attend, what grade is he/she in, and are there any academic difficulties?*
Please list any specific medical problems:*
Please list any previous or current mental health providers and list all psychiatric medications child is presently taking:*
File Uploads
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Accepted file types: pdf, doc, docx.
Service authorizations and any additional documents can be uploaded here.