Parent/Legal Guardian Information

Full Name of parent/guardian completing this form:*
Name of other parent/legal guardian
Current Address*
Insurance Provider/Carrier (Choose one or multiple if applicable)*

Child's Information

Child's Name*
Legal Sex*
Is your child sexually active?
Was your child adopted?
Does your child have siblings?
Please rate your relationship with your child*

Academic Information

Intake Information

Please complete on behalf of your child. 

How intense if your child's emotional distress?*
Over the past two weeks, have you or your child noticed any of the following?
Over the past two weeks, have you or your child noticed any of the following?
  Not at all Several Days More than half of the days Nearly everyday
Feeling nervous, anxious, or on edge
Not being able to sleep or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid, as if something awful might happen
Depressed mood
Loss of interest
Impulsivity / risk taking
Crying spells
Changes in appetite
Excessive energy
Low energy / fatigue
Blackouts or loss of time
Hallucinations / delusions
Excessive guilt
Distrust of others
Using drugs/alcohol
Racing thoughts
Irritability / anger
Decreased need for sleep
Extreme sleepiness
Avoiding problems
Self-harming behavior
Suicidal thoughts or attempts
School issues
Legal issues
Overall, how much do the problems affect your child's ability to perform school, get along with others, and perform daily tasks such as chores?*
1 being mildly disruptive | 10 being incapacitating
How often does your child use/take the following? (If N/A, check "never" in one row)
How often does your child use/take the following? (If N/A, check "never" in one row)
  Never Suspected Sometimes Occasionally Often
Opioids/opiates (pills, Heroin, Fentanyl, etc.)
Marijuana / THC
Benzodiazepines (Xanax, Valium, Ativan, etc.)
Methamphetamines (Meth, ice, speed)
Non-prescribed Stimulants (Adderall, Ritalin, Concerta, etc.)
Non-prescribed Methadone or Suboxone (Subutex)
Non-prescribed sleeping pills
Non-prescribed muscle relaxers
LSD / Mushrooms / Ecstasy / DMT
PCP / other hallucinogens
Synthetic marijuana
Ketamine / Tranquilizers

Psychological / Psychiatric / Physical History

Please complete on behalf of your child. 

Has your child ever displayed any of the following? (Check all that apply)
Has your child ever attended therapy before?*
Has your child ever been hospitalized for psychological or psychiatric reasons?*

About Your Child

Please complete on behalf of your child. 

Does your child agree that the problem he/she is seeking help for is problematic?*
Parent/Guardian Full Name*
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Mood and Feelings Questionnaire

Please allow your child to fill out the following questionnaire, with your assistance if needed. 


This form is about how you might have been feeling or acting recently.

For each question, please check how you have been feeling or acting in the past two weeks.

If a sentence was not true about you, check NOT TRUE.

If a sentence was only sometimes true, check SOMETIMES.

If a sentence was true about you most of the time, check TRUE.

  Not True Sometimes True
I felt miserable or unhappy
I didn't enjoy anything at all
I was less hungry than usual
I ate more than usual
I felt so tired I just sat around and did nothing
I was moving and walking more slowly than usual
I was very restless
I felt I was no good anymore
I blamed myself for things that weren't my fault
It was hard for me to make up my mind
I felt grumpy and cross with my parents
I felt like talking less than usual
I was talking more slowly than usual
I cried a lot
I thought there was nothing good for me in the future
I thought that life wasn't worth living
I thought about death or dying
I thought my family would be better off without me
I thought about killing myself
I didn't want to see my friends
I found it hard to think properly or concentrate
I thought bad things would happen to me
I hated myself
I felt I was a bad person
I thought I looked ugly
I worried about aches and pains
I felt lonely
I thought nobody really loved me
I didn't have have any fun at school
I thought I could never be as good as other kids
I did everything wrong
I didn't sleep as well as I usually sleep
I slept a lot more than usual

PHQ-9 Modified for Adolescents (PHQ-A)

Please allow your child to fill out the following questionnaire, with your assistance if needed. 


How often have you been bothered by each of the following symptoms during the past 2 weeks?

For each symptom, mark the box beneath the answer that best describes how you have been feeling.

  Not at all Several Days More than half the days Nearly everyday
Feeling down, depressed, irritable, or hopeless?
Little interest or pleasure in doing things?
Trouble falling asleep, staying asleep, or sleeping too much?
Poor appetite or overeating?
Feeling tired or having little energy?
Feeling bad about yourself or feeling that you are a failure or that you have let yourself or your family down?
Trouble concentrating on things like school work, reading, or watching tv?
Moving or speaking so slowly that other people could have noticed? OR the opposite - being so fidgety or restless that you were moving around a lot more than usual?
Thoughts that you would be better off dead or of hurting yourself in some way?
In the past year, have you felt depressed or sad most days, even if you felt okay sometimes?*
If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*
Has there been a time in the past month when you have had serious thoughts about ending your life?*
Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?*

**If you have had thoughts that you would be better off dead or of hurting yourself in some way, please discuss this with your Health Care Clinician, go to a hospital emergency room, or call 911.


Suicide Hotline Number: 988

Check either YES or NO

Please allow your child to fill out the following questionnare, with your assistance if needed. 

Have you ever ridden in a car driven by someone (including yourself) who was high or had been using alcohol or drugs?*
Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?*
Do you ever use alcohol or drugs while you are by yourself?*
Do you ever forget things you did while using alcohol or drugs?*
Do your family and friends ever tell you that you should cut down on your drinking or drug use?*
Have you ever gotten into trouble while you were using alcohol or drugs?*

Policies and Consent

Please complete on behalf of your child. 

Confidentiality & Privacy Policy

All interactions which take place at Devaraj Behavioral Healthcare or rendered by affiliates there of, will remain confidential. This includes requests by telephone, all therapy, recovery coaching, or scheduling notes. All sessions with therapist may be recorded for quality assurance, and/or improving care. In the event of a recording you will be verbally notified by the Therapist/Provider. You may give expressed permission to disclose specific details or general health information to any person or agency you designate. You have the right to withdraw this agreement at anytime, but it should be done so in writing with a 48-hour notice to adequately fulfill the request. By signing below you are agreeing to this policy and the terms of this agreement willfully on behalf of the adolescent. (Before signing please review limits to this agreement below):

Limits to this agreement:

1. In some legal proceedings a judge may issue a court order, this would require our providers to provide documentation, records, or possibly testify in court. While our interest is protecting your information, legally binding requests may present a situation which would be out of our control.

2. If any provider or employee learns or has evidence to believe there is physical abuse, sexual abuse, or neglect of any person under 18 years of age, we will report this incident to Child Protective Services and all confidentiality may become null and void depending on context, severity, and form of disclosure.

3. If any provider or employee learns of or has evidence to believe that an elderly, disabled, or incapacitated adult is being abused, exploited, neglected, or harmed, we will report the findings to Adult Protective Services. In the event of this report all confidentiality may become null and void depending on context, severity, and form of disclosure.

4. If any provider or employee has reason to believe that you may be a danger to yourself or others, and believe you are likely to follow through with actions as such, we may be obligated to seek hospitalization or contact law enforcement depending on context, severity, and form of disclosure. It must be noted that this topic may be discussed with providers, but if the provider feels there is adequate risk beyond therapeutic discussion of topic; or cannot guarantee without doubt the safety of you or others this limit may break the agreement, and all confidentiality may become null and void.

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Consent for Treatment and Billing

Please review policy and sign at the end of the section:

The undersigned patient or responsible party (parent, legal guardian or medical power of attorney) consents to, and
authorizes services by Devaraj Behavioral Healthcare. These services may include but are not limited to:

- Psychotherapy
- Medication Services
- Recovery Coaching
- Supportive Counseling
- Case Management
- Group Counseling
- Lab / Toxicology Tests
- Diagnostic Procedures
- Mental Health Assessments
- Psychiatric Assessments
- Appropriate Alternative Therapy

The undersigned understands that the primary method of payment for services provided by Devaraj Behavioral Healthcare will be billed to presented insurance if applicable. This includes both private insurances, state Medicaid/Medicare. In the event these services are not covered by insurance the cost of said service would be sole responsibility· of the undersigned. In the event of rejected or uncovered services the undersigned will be notified by office staff before proceeding with treatment or resuming services.

The undersigned understands that he/she has the right to:

1. Receive a copy of this agreement
2. Request a list of services rendered
3. Withdraw consent from this agreement at any time (must be in writing).

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Telehealth / Telemedicine / Teletherapy Policy and Agreement

This Informed Consent for Telehealth contains important information focusing on providing healthcare / mental health services using the phone or the Internet.

Benefits and Risks of Telehealth
Telehealth refers to providing medical or mental health services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telehealth is that the patient and clinician can engage in services without being in the same physical location. This can be helpful particularly during the Coronavirus (COVID-19) pandemic in ensuring continuity of care as the patient and clinician likely are in different locations or are otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person treatment and telehealth, as well as some risks. For example:

- Risks to confidentiality. As telehealth sessions take place outside of Devaraj Behavioral Healthcare’s office, there is potential for other people to overhear sessions if you are not in a private place during the session. On our end, we will take reasonable steps to ensure your privacy. It is important; however, for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in a session only while in a room or area where other people are not present and cannot overhear the conversation.

- Issues related to technology. There are many ways that technology issues might impact telehealth. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.

- Crisis management and intervention. Normally, we will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. We may not have an option of in-person services presently, but in a crisis situation, you may require a higher level of care. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work.

The same fee rates will apply for telehealth as apply for in-person therapy. Some insurers are waiving co-pays during this time. It is important that you contact your insurer to determine if there are applicable co-pays or fees which you are responsible for. Insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic therapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in telehealth sessions in order to determine whether these sessions will be covered.

Informed Consent
This agreement is intended as a supplement to the general informed consent agreed to at the outset of treatment and does not amend any of the terms of that agreement.

Your signature or E-sginature below indicates agreement with its conditions and indicates you are willfully and within capacity to sign agreeing to its binding terms.

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Review, Sign, and Submit

By signing, I agree that I (undersigned) have answered the following questions on behalf of the adolescent as a parent, guardian, or medical power of attorney to initiate medical/behavioral health/substance abuse services rendered by licensed, trained professionals affiliated with Devaraj Behavioral Healthcare.

Full Legal Name*
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