Client and Family History Form CATALPA FAMILY HX FORM "*" indicates required fields Step 1 of 4 25% INSURANCE INFORMATION We will be unable to schedule your child for an appointment unless all insurance information is provided.Insurance Type (select all that apply):* No Insurance, will be self pay Commercial Insurance Medicaid/Badgercare Attach insurance card(s)Max. file size: 512 MB.Please include front and back of each card.Medicaid Member ID: Commercial Insurance Company Name: Member ID: Group Number: Effective Date: Subscriber's name: Subscriber's Date of Birth: Subscriber's Relationship to Client: Subscriber's Address: Mailing Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Subscriber's Employment StatusMake SelectionEmployed Full-TimeEmployed Part-TimeSelf-employedNot employedHomemakerRetiredStudentSubscriber's Employer: Additional Commercial InsuranceMake SelectionPatient does not have secondary insurancePatient has secondary insuranceCommercial Insurance Company Name: Member ID: Group Number: Effective Date: Subscriber's name: Subscriber's Date of Birth: Subscriber's Relationship to Patient: Subscriber's Address:Make SelectionSame as subscriber #1's addressDifferent address than subscriber #1's listed aboveSubscriber's Address: Mailing Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Subscriber's Employment StatusMake SelectionEmployed Full-TimeEmployed Part-TimeSelf-employedNot employedHomemakerRetiredStudentSubscriber's Employer: Employee Assistance Program (EAP) Authorization:Make SelectionNo EAP authorization.Yes, there is an EAP authorizationEAP Company Name: EAP Company Phone Number: EAP Authorization Number: EAP Effective Date: Number of visits covered by EAP authorization: PRE-REGISTRATION INFORMATION Please initial next to each line to indicate that you have read and understand each item:Initial that you have read:* ** If your situation requires immediate intervention prior to an appointment at Catalpa, call 911 or go to the nearest emergency room or psychiatric hospital as directed by your insurance coverage.Initial that you have read:* ** Any cancellations should be made at least 24 hours in advance of your appointment. If you need to change an appointment, call as far ahead as possible to reduce the wait time for your next appointment. If you do not show for 2 initial appointments within a 3-month period, you will not be allowed to reschedule for 3 months.Initial that you have read:* ** We recommend calling your insurance to verify in-network status along with mental health benefits and telehealth coverage. Contact information is located on the back of your insurance card. Continued: (if you are starting School Based Services, please skip/go to next page)Initial that you have read: Catalpa is having all appointments completed through a secure online video. For families who do not have access to a device that will support a video appointment, our clinics have a kiosk room that can be used.Initial that you have read: The first appointment will be with an intake specialist. At the end of your intake appointment, the counselor will work to connect you with services. We are in a time of high need for mental health therapy services. Catalpa, and other similar agencies within our community, are scheduling 4-6 weeks out for therapy services and using waitlists to help capture the demand. Our first priority will be to get you connected with a therapist within 4-6 weeks, either within or outside of our agency, and a waitlist may be used on a limited basis when no other services are available. Some internal availability may be available sooner for trainees with limited insurances or telehealth only appointments. Catalpa also offers several group options, for all ages, with more immediate access after the intake appointment. Group may be sufficient for your child’s needs as a stand-alone service. If you are placed on a waitlist, you will have the option of a brief therapeutic check in every few weeks until we can get you started or you can use our Urgent Clinic services should a crisis arise or you are in need of additional support.Initial that you have read: If you are interested in psychological testing or an ADHD evaluation for your child, please know that these specialty services are in high demand. The initial appointment will be an opportunity to share your concerns with an intake specialist to see whether you child would qualify for these services. If so, a referral will be made and your child will be put on a waitlist.Initial that you have read: Both the client and a parent/guardian need to be together and in the same physical location for the intake appointment. Families will be asked to provide the address for their location at the time of the intake. Families must be in the state of Wisconsin during the telehealth visit. Please plan ahead for your initial session. Be in a safe and private location with minimal distractions; the telehealth session cannot be held in a moving vehicle. Who referred you to Catalpa Health? Form completed by:* Client’s legal first name:* Client’s preferred name: Client’s legal middle name: Client’s legal last name:* Client’s date of birth: GenderMake SelectionMaleFemaleClient's address:* Mailing Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Ethnicity:Make SelectionNon-Hispanic or LatinoHispanic or LatinoRace: Client's primary language: Parent/legal guardian's primary language: Will an interpreter be helpful for phone communication and during appointments? Yes No Other Religion: (optional) Important client and family cultural information: Primary concern: What treatment services are you seeking? Please select any that apply. Individual therapy Group therapy Medication management Intensive Outpatient Services (3-4 hours daily group treatment) ADHD Evaluation (occurs over multiple appointments) Concussion Evaluation Psychological/ Neuropsychological Testing (this service line is for providing diagnostic clarification for children with developmental/ cognitive concerns, complex mental health or medical issues.) FAMILY AND SOCIAL HISTORYParent Name #1:* Relationship to client*Select this parent's relationship to the clientMotherFatherStepparentLegal GuardianFoster ParentOtherSpecify relationship to the client: Parent 1 Address:Make SelectionSame as client's address listed aboveDifferent address than client's listed aboveParent 1 Address: Mailing Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Parent 1 phone number:Parent 1 email address: Occupation: Parent Name #2: Relationship to client:Select this parent's relationship to the clientMotherFatherStepparentLegal GuardianFoster ParentOtherSpecify relationship to the client: Parent 2 Address:Make SelectionSame as address listed for clientSame as address listed for parent 1Different addressParent 2 Address: Mailing Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Parent 2 phone number:Parent 2 email address: Occupation: Additional parents to list?make selectionyesnoParent Name #3 Relationship to client:Select this parent's relationship to the clientNot applicableStepparentLegal GuardianFoster ParentMotherFatherOtherIf other, specify relationship to the client: Parent 3 Address:Same as address listed for clientSame as address listed for parent 1Same as address listed for parent 2Different address than what is listedParent 3 Address: Mailing Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Parent 3 phone number:Parent 3 email address: Occupation: Parent Name #4 Relationship to client:Select this parent's relationship to the clientNot applicableStepparentFoster ParentLegal GuardianMotherFatherOtherIf other, specify relationship to the client: Parent 4 Address:Make SelectionSame as address listed for clientSame as address listed for parent 1Same as address listed for parent 2Different address than what is listedParent 4 Address: Mailing Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Parent 4 phone number:Parent 4 email address: Occupation: Was the client adopted?Make SelectionNoYesWho has parental rights for client? Mother Father Other (legal guardian, county, etc.) *Please contact us directly at 920-702-3204 to discuss if there has been any court appointed guardianship changes or placement orders. Has Catalpa Health's privacy team reviewed the guardianship change? Yes No Currently working with the privacy team at Catalpa **Please contact us directly at 920-702-3204 to discuss if there has been any court appointed guardianship changes or placement orders. **Are there any legal reasons either parent or guardian cannot be present or alone with a child?Make SelectionNoYesIf yes, explain:Family currently living in home:Parent(s) and Siblings not living in home:List any of the client’s current or past legal issues: AUTISM DIAGNOSISHas the client been diagnosed with Autism?Make SelectionNoYesPlease note, our agency does not offer Applied Behavior Analysis (ABA) therapy for Autism. If Autism is the primary reason for seeking therapy, we may refer to an agency that does offer this type of treatment. Additionally, our agency typically does not provide individual therapy while a child is also receiving ABA therapy for Autism. Once we learn more about your child's needs, we will inform you whether individual therapy with Catalpa could be an option.Aside from Autism, are there other diagnoses or concerns you have for the client related to emotions and behaviors? For example: anxiety, depression, attention/ADHD, speech/language delays, developmental delayWhich agency and psychologist diagnosed the client with Autism? When did this diagnosis happen? Were there any services recommended at the time of service, such as in-home or intensive Autism intervention?Make SelectionNoYesWhat were they and were these services pursued? How would you rank the severity of the cleint's autism and their level of functioning?Make SelectionMildModerateSevereHas the client received any treatment services in the past related to their autism diagnosis?Make SelectionNoYesExample of treatment services: in-home therapy, outpatient therapy, any autism based therapy, occupational therapy, physical therapy, speech services, IEP in schoolWhat treatment and what was the length of time they were in this treatment? Example of treatment services: in-home therapy, outpatient therapy, any autism based therapy, occupational therapy, physical therapy, speech services, IEP in schoolPlease list any services the client is receiving. Include the agency providing services, along with the services they are receiving. Which option best describes how the client communicates their wants and/or needs? Full sentences Short 2-3 word phrases Single words Non-verbally through gestures, sign language or guiding you to objects Other What have other professionals told you about the severity of the client's autism and ranked their level of functioning?Make SelectionMildModerateSevereHas any cognitive (IQ) testing been done?Make SelectionNoYesHas the client been given any previous diagnoses of intellectual disability and/or cognitive disability or developmental delays? CHILD & ADOLESCENT SYMPTOM CHECKLIST For each item below, check the category that best describes your child DURING THE PAST 6 MONTHS.Depressed or unusually sad None Mild Moderate Severe Past Irritable None Mild Moderate Severe Past Loss of interest in previously enjoyable activities None Mild Moderate Severe Past Loss of appetite None Mild Moderate Severe Past Overeating None Mild Moderate Severe Past Difficulty with sleep None Mild Moderate Severe Past Suicidal thought(s) None Mild Moderate Severe Past Aggressive or violent thought(s) None Mild Moderate Severe Past Self-injuring behaviors None Mild Moderate Severe Past Feelings of worthlessness and/or hopelessness None Mild Moderate Severe Past Loss of energy None Mild Moderate Severe Past Hears voices that others can’t/sees things others do not None Mild Moderate Severe Past Has bizarre thoughts that others cannot understand or believe None Mild Moderate Severe Past Worries excessively about multiple things None Mild Moderate Severe Past Excessive anxiety when performing in front of others None Mild Moderate Severe Past Excessive worry about being teased by peers None Mild Moderate Severe Past Social situations are avoided or endured with intense anxiety None Mild Moderate Severe Past Upset/worries when separating from parents/caregiver/home None Mild Moderate Severe Past Worries about getting lost or kidnapped None Mild Moderate Severe Past Physical/bodily complaints None Mild Moderate Severe Past Intense fear of a specific object or situation None Mild Moderate Severe Past Obsessive/recurrent thoughts (e.g., health concerns, etc.) None Mild Moderate Severe Past Repetitive behaviors (e.g., hand washing, doing things 3 times) None Mild Moderate Severe Past Seeing, feeling or hearing something bad that happened in past None Mild Moderate Severe Past Is easily startled None Mild Moderate Severe Past Always feels on guard None Mild Moderate Severe Past Has difficulty paying attention (in play, school, other activities) None Mild Moderate Severe Past Requires multiple reminders when given directions None Mild Moderate Severe Past Appears to act before thinking None Mild Moderate Severe Past Does not follow instructions None Mild Moderate Severe Past Is forgetful or loses things None Mild Moderate Severe Past Easily distracted None Mild Moderate Severe Past Is fidgety or squirms or can’t stay in seat None Mild Moderate Severe Past Runs or climbs excessively, is hyperactive None Mild Moderate Severe Past Talks excessively None Mild Moderate Severe Past Has difficulty waiting turn None Mild Moderate Severe Past Interrupts or intrudes on others None Mild Moderate Severe Past Refuses to eat None Mild Moderate Severe Past Eats a lot and then vomits None Mild Moderate Severe Past Smokes cigarettes, drinks alcohol, or abuses alcohol None Mild Moderate Severe Past Bullies, threatens, or intimidates others None Mild Moderate Severe Past Initiates physical fights None Mild Moderate Severe Past Has been physically cruel to animals None Mild Moderate Severe Past Has shoplifted or stolen items None Mild Moderate Severe Past Has deliberately set fires None Mild Moderate Severe Past Has deliberately destroyed others’ property None Mild Moderate Severe Past Lies to obtain goods or to avoid obligations None Mild Moderate Severe Past Has run away from home overnight on at least two occasions None Mild Moderate Severe Past Is truant from school None Mild Moderate Severe Past Actively defies or refuses to comply with adult rules None Mild Moderate Severe Past Deliberately annoys others None Mild Moderate Severe Past Blames others for their mistakes or misbehavior None Mild Moderate Severe Past Easily annoyed by others None Mild Moderate Severe Past Is spiteful or vindictive None Mild Moderate Severe Past Avoids eye contact with others None Mild Moderate Severe Past Unusual preoccupation with objects or routines None Mild Moderate Severe Past Does not like changes None Mild Moderate Severe Past Hand–flapping, shrieks, puts objects in mouth None Mild Moderate Severe Past Failure to initiate or respond to social interactions None Mild Moderate Severe Past Makes repetitive movements and is unaware of it None Mild Moderate Severe Past FAMILY MENTAL HEALTH INFORMATION Please check all that applyDepression Grandparent Mother Father Sibling Other Bipolar (Manic-Depression) Grandparent Mother Father Sibling Other Psychosis or Schizophrenia Grandparent Mother Father Sibling Other ADHD Grandparent Mother Father Sibling Other OCD or Obsessive Compulsive Grandparent Mother Father Sibling Other Anxiety Grandparent Mother Father Sibling Other PTSD Grandparent Mother Father Sibling Other Autism Grandparent Mother Father Sibling Other Alcohol or Drug Abuse Grandparent Mother Father Sibling Other Suicidal Thoughts or Behaviors Grandparent Mother Father Sibling Other Other Mental Health: Grandparent Mother Father Sibling Other Notes: PAST MENTAL HEALTH TREATMENTHas your child been given any previous mental health diagnoses?Make SelectionYesNoUncertainExplain:Has your child been to counseling in the past?Make SelectionNoYesDates: Has your child been hospitalized for psychiatric reasons?Make SelectionNoYesDates & hospital:DEVELOPMENTAL HISTORYDuring pregnancy, did the mother experience any illness or complications?Make SelectionNoYesUnknownExplain: Did the client have any complications at birth or as an infant/toddler?Make SelectionNoYesUnknownExplain: Was the client born prematurely?Make SelectionNoYesUnknownHow many weeks at birth: Client’s weight at birth: Has the client’s doctor, caregiver or teacher expressed any developmental concerns in these areas? Crawling Walking Speaking Toilet training Please list any significant medical issues (including allergies):EDUCATIONAL HISTORYClient’s current grade level: Current School: Education:Make SelectionRegular EducationSpecial EducationType of IEP LD EBD CD S/L OHI Autism TBI Does the client have a history of learning challenges? Please include grades and specific challenges?Make SelectionNoYesPlease explainCheck any of the options that best describes the client socially: Makes friends easily Maintains friendships Socially withdrawn Has few but close friends Frequent peer conflict Please describe the client's assets and strengths:CLIENT AND FAMILY MEDICAL HISTORYClient’s current primary care provider's name, if there is not a primary care provider please list n/a:* Clinic location: Other treating physicians: Clinic location: Please list all CURRENT medications the client is taking:Please list past medications the client has taken (previous 3 years) to treat mental health symptoms:HEALTH HISTORY Please indicate below if any of the following apply to: Client, Mother, Father, Sibling, Grandparent, or OtherHeart Disease Client Mother Father Sibling Grandparent Other Pulmonary Disease Client Mother Father Sibling Grandparent Other Hyper- or Hypo- thyroidism Client Mother Father Sibling Grandparent Other Diabetes Client Mother Father Sibling Grandparent Other Hyper- or Hypo- tension Client Mother Father Sibling Grandparent Other Liver Disease Client Mother Father Sibling Grandparent Other Kidney Disease Client Mother Father Sibling Grandparent Other Migraines Client Mother Father Sibling Grandparent Other Asthma Client Mother Father Sibling Grandparent Other Gastrointestinal Difficulties Client Mother Father Sibling Grandparent Other Has the client experienced or witnessed anything that is perceived as traumatic?Make SelectionNoYesUncertainHas the client experimented or abused any alcohol and/or drugs?Make SelectionNoYesUncertainPlease be aware that Catalpa is not a primary AODA treatment center. Our team will treat clients for issues related to substance us and/or abuse, but do not treat addiction if it is the primary mental health concern. Date the client last used: Substance(s) used: SEIZURE HISTORYHas the client ever experienced a seizure?Make SelectionNoYesAge(s): Type(s): HEAD INJURY HISTORYHas the client ever experienced a serious hit on the head?Make SelectionNoYesDate(s) of injury: Was there a loss of consciousness?Make SelectionNoYesDid it result in a concussion?Make SelectionNoYes Δ