Transcription of Children’s Mental Health Child/Adolescent …
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Children’s Mental Health Child/Adolescent …
Page 1 of 8 Children s Mental Health Child/Adolescent Diagnostic assessment (TO BE COMPLETED BY PARENT/CAREGIVER)PART 1 Please provide the following information in preparation your interview with your Mental Health NAME (FIRST, MI, LAST)CLIENT NUMBERREFERRAL SOURCEREASON FOR REFERRAL_____Living situationParent s Home l RENT l OWNR esidential Care/Treatment Facility** l HOSPITAL l TEMPORARY HOUSING l RESIDENTIAL CARE l NURSING HOMEO ther** l FRIEND S HOME l RELATIVE/GUARDIAN S HOME l HOMELESS**IDENTIFY PERSON S NAME OR FACILITYP rimary HouseholdHousehold member nameRelationship to childAgeOccupation/SchoolHighest level of education Quality of relationshipSTREET ADDRESS (If different from child s address listed on Demographic Information form.)
Page 1 of 8 Children’s Mental Health Child/Adolescent Diagnostic Assessment (TO BE COMPLETED BY PARENT/CAREGIVER) PART 1 – Please provide the following information in preparation your interview with your
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