Children and Youth Assessment | Davis Behavioral Health

Client Name *

Phone Number *

Email *

SAFETY CONCERNS: check all safety concerns that apply to your child

Accidently hurting him/herself Suicidal thoughts, threats or attempts Hurting someone else(assaultive behavior to family members or peers) Other safety concerns

Describe the safety concerns you checked.

MEDICATION: check all Anti-Anxiety / Anti-Convulsant drugs currently being taken by your child *

MEDICATION: check all Anti-Depressant drugs currently being taken by your child *

MEDICATION: check all Anti-Psychotic drugs your child is currently taking *

MEDICATION: check all Mood Stabilizers drugs currently being taken by your child *

Depakote Lithium Tegratol None

Other Medications or Vitamins: *

STRESSORS: check all stressors below that apply to your child *

Describe any stressors you checked above.

FAMILY PSYCHIATRIC and/or SUBSTANCE ABUSE HISTORY: check all items that apply to your child's family *

Describe how items checked above relate to your child. *

Is there any other information you think would be important for us to know about your child or your family?