Stress and Anxiety Services of New Jersey, PA __________________________________________________________________________________________________________________________________________
A-1 Brier Hill Court		Phone: (732) 390-6694
East Brunswick, NJ 08816		Fax: (732) 432-7206
www.StressAndAnxiety.com		Email: StressAndAnxiety@Comcast.net

Hello, and welcome to our link for New Client Forms for Minors!

If you have already contacted our office and scheduled an appointment, this link is designed to save you time during our initial interview.

On the following pages are two forms; a one-page Insurance Information Form, and a three-page Pre-Intake Form. These forms are NOT set up to be filled out online and electronically submitted. Instead, print out this form (you can tell your printer to print out pages 2-5, so that you only get the form itself- also, please remember to set your printer up so that it prints in portrait, NOT in landscape). Then fill out this form before you come in for your first session and bring it in with you when you come in for your appointment.

This will allow for the best use of our time during the initial session, as there are many other questions that we will review during our initial meeting. If you are not sure how to answer something, just leave it blank. We will review all the information you have provided in these forms, so that if you need to clarify anything, you can do so at that time.

Although we do not take insurance at this time, please note that we still request that you fill out the insurance form for our records. Thank you in advance. Looking forward to working with you.

Stress and Anxiety Services of New Jersey, PA __________________________________________________________________________________________________________________________________________
A-1 Brier Hill Court		Phone: (732) 390-6694
East Brunswick, NJ 08816		Fax: (732) 432-7206
www.StressAndAnxiety.com		Email: StressAndAnxiety@Comcast.net

INSURANCE INFORMATION FORM-Please print clearly

Name of child/adolescent _______________ Birth date

Name of parent or guardian ________________________________________

Home phone (_______)_____________ Business phone (______)________________

Cell phone of parent(______)________________ Email of parent_________________________

Address ______________________________________________________________

Whom may we thank for referring you? (name)__________________________________

(address)________________________________________(tel)____________________

Marital status of parent: Single ____ Married ___ Divorced ____ Widowed ____

Social Security number of insured ________-_______-_________

Person financially responsible for this account _________________________________

Relationship to client ____________________ Address (if different from client’s)

___________________________________________________________________

Insurance company name & address_________________________________________

_____________________________________ Insurance ID # ___________________

Subscriber’s name (if different from client’s) __________________________________

Subscriber’s birth date (if different from client’s) _______________________________

I authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for all for all charges, regardless of insurance coverage.

Parent or Guardian signature ___________________________ Date ____________

Stress and Anxiety Services of New Jersey, PA __________________________________________________________________________________________________________________________________________
A-1 Brier Hill Court		Phone: (732) 390-6694
East Brunswick, NJ 08816		Fax: (732) 432-7206
www.StressAndAnxiety.com		Email: StressAndAnxiety@Comcast.net

PRE- INTAKE FORM FOR MINORS- please print clearly

Name of minor___________________________ DOB ____________ Age ______

Parent(s) (first name/age) __________________________________________________

Siblings (first names/ages) ____________________________________________________

Who is living in your present home with client? _______________________________________

Grade level ___________________________________

Name of School __________________________________________________

Address of school (NO CONTACT will be made without written permission from parent/guardian)

__________________________________________________________________________

Telephone number of school __________________ School contact _______________________

Has client been classified? yes no (if yes, please try to bring any testing results)

If yes, has there been an IEP (504 plan) developed? yes no (if yes, please try to provide a copy)

Parent Employed? No Part Time Full Time

(if no, skip to Present medical conditions)

Where employed? _______________________________________________

Present employment position _________________________________________

_______________________________________________________________

Present medical conditions of client (high blood pressure, diabetes, allergies, etc.)

________________________________________________________

History of medical (non-psychiatric) hospitalization? Yes No

If yes, please indicate year and reason

_______________________________________________________________

Is client taking any prescription medication now (psychiatric or otherwise)? Yes No

If yes, indicate Name of Medication, Dosage, Since When Taken, and any Present Side Effects:

________________________________________________________________

Please provide the name, address and phone number of any physician currently prescribing

psychiatric medication for your child. If you need more room, please write on separate 8”x 11” paper.

________________________________________________________________

Please list any additional psychiatric medications that your child has previously been on:

________________________________________________________________

Has your child had any psychiatric hospitalizations? Yes No

If yes, please indicate where and approximate dates:

___________________________________________________________________

Has your child been in therapy before? Yes No

If yes, please indicate the name of the therapist, address and telephone number,

and the approximate beginning and end dates of treatment. If multiple therapists,

it is not necessary to provide names of people you have seen for only a very short time.

If you need more room, please write on separate 8” x 11” paper.

_______________________________________________________

________________________________________________________

Thank you for your information.

Name of child/adolescent _____________________________ Birth date ______________

PRE- INTAKE FORM FOR MINORS- please print clearly

Name of child/adolescent _______________ Birth date