Page 98 - Juvenile Practice is not Child's Play

Phone:

Email, e-text, and website addresses:
Does the client or his or her parent or guardian have paper or electronic documents that would contain

identifying or contact information for this hospital or information about the client’s treatment or performance?

Has the client ever been in a mental hospital or institution? Yes No

For each hospital or institution:

Name, street address, and city of hospital:

Admission date:

Discharge date: Event[s] leading to hospitalization:

Diagnosis:

Name[s] of physician[s] and other individual professional personnel:

For each individual known:

Phone:

Email, e-text, and website addresses:

Does the client or his or her parent or guardian have paper or electronic documents that would contain

identifying or contact information for this hospital or institution or information about the client’s

treatment or performance?

Has the client ever been found mentally incompetent by a court? Yes No

For each occasion:

Name and location of court: Name of judge:

Name[s] of attorney[s]: Date of adjudication: Nature of proceeding:

Event[s] leading up to proceeding:

Does the client or his or her parent or guardian have paper or electronic documents that would contain

this contact information or information about the client’s treatment or performance?

Has the client ever been treated by a psychiatrist or psychologist? Yes No

For each treating professional:

Name: