How to access the information on this page:
- Directly on this page
2. Mental Health Checklist as a hard copy
3. Mental Health Checklist to download and fill out on your device, making updates anytime
Date: ___________________
Child’s name: _______________________________________________ Date of birth: __________________
Therapist’s name: ____________________________________________ Phone: _______________________
Therapist works for: _________________________________________________________________
Email: _______________________________________________________
Collect Information, Monitor & Report |
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Review past records or contact previous providers
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Obtain family history
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Obtain mental health assessments, such as DAF
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Obtain diagnosis(es)
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Medication Management |
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Name, address and phone number of current medication provider:
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Medication(s) & dosage(s):
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Attend medical-somatic (med-som) appointments (appointments with the prescriber)
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Invite parent/caregiver to attend med-som appointments
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Parent/caregiver attended med-som appointment(s)?
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Appointment history:
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Treatment(s) & Services |
Type(s) of treatment/service received:
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Start date:
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Frequency:
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Treatment Goals:
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Progress/Engagement with Therapy:
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Concerns:
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Additional Service Recommendations:
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Anticipated Treatment End:
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