More Information: www.BendPsychology.Com

Bend Psychological Services
965 NE Wiest Way, No. 2
Bend Oregon, 97701
Office: 541 388-5660
Fax:  541 323-2000

This information is confidential and protected

Please Print and Complete this Form

You are not required to submit this form using the internet. You may:

  • speak with us and ask that the minimal information be included to our record
  • complete this form on-line and submit the results by e-mail, or 
  • print this form, complete it by hand and bring it to your first appointment.

Student/Teenager/Child Information Form

Name of Person Completing this form

Relationship to Student/Teenager

Your E-Mail

Your phone number  

Parent Information

Parent(s) name(s)




Phone(s)  (work, home, cell, pagers, how and when to best to contact)


Parent(s)  employment (employer, type of work, days, hours, availability to speak)


How and when parents can be reached (how, day, night, emergency, messages)


Martial history (date of marriage, divorces, current marital status, on-going or recurrent problems)


Custodial Parent(s)



Phone(s)  (work, home, cell, pagers, how and when to best to contact)


Legal Gaurdian(s)



Phone(s)  (work, home, cell, pagers, how and when to best to contact)


How and when Gaurdian(s) can be reached (how, day, night, emergency, messages)


Child's Information

Child's Name

Date of birth




Color eyes

Color hair

Adoption history (if adopted)


Brothers and Sisters (name, age, by marriage or biological relationship)


Grade in school

School history (drop out, expulsions, suspensions, held back, when, reasons)


Most recent physical (when, purpose, what was done, findings)


Medication allergies (drug name, reaction, treatment)


Current medications (drug name, when, dosage, purpose, name of prescribing physician)


Past medications (when, drug name, purpose, effectiveness, problems)


Current medical problems and treatment (allergies, skin, infections, injury, etc..)


Previous hospitalizations  or surgery (when, what for, treatment, how long)


History of major injury or accident (when, what happened, treatment, lasting effects)


Birth history (trauma, complications, problems)


Criminal history (when, arrests, charges, detention, court appearance, tickets, fines)


Employment history (when, employer, type of work, problems, successes)


Alcohol, chemical and other drug use (when, used what, how long)


Traumatic life experiences (physical, psychological, when, what happened, treatment, lasting impacts)


Therapy or counseling history (when, name of person, title, diagnosis, treatment method, length of treatment, outcome)


Recent or unusual behavior  that worries you.



History of destructive, violent, self-harming or suicidal behavior (when, what did your child do, your response, response by others, treatment if any)


Psychiatric hospitalization history (when, where, what for, how long, treatment, diagnosis)


Residential treatment history (when, what for, voluntary or mandatory education,  treatment, how long, outcome)


Special program history (when, what for, voluntary or mandatory education or treatment, how long, outcome)


Special education plan (when, what was the plan, outcome)


Family History

Family issues, problems, conflicts, current or past that affect the family and child


Family history of psychiatric problems including relatives (who, relationship, diagnosis or disorder, treatment, medications, outcome)


Deaths in the family, suicide or accidental loss of life (when, who, relationship, how, impact on family and child)


Family history of alcohol, chemical or drug use (who, when, what, how long, treatment, outcome)


Family health (who, medical problems or conditions, when, how long)


Legal problems (what, when, how long, outcome or current status)


Custody, visitation or child support issues


Child's Medical History

Does your child have a potential problem or has your child ever been treated by a physician for any of the following medical problems.

Cancer Indigestion
Tension head aches Vomiting
Migraines Lower stomach (intestinal problems)
Diabetes Diarrhea
Thyroid problems Back problems
Seizure(s) Heart problems
Tumor(s) Circulation
Asthma Kidney problems
Lung disease Bladder problems
Breathing problems Liver problems
Ulcer(s) Eye problem(s)
Stomach problems Vision problem(s)

Have your child ever been treated by a physician for any of the following medical problems.

Head injury
Multiple sclerosis
Addison's disease
Reoccurring pain
Chronic pain

Please describe the above problems you checked in more detail including current or past treatment and whether or not the problem is currently in remission, managed or under control. You may use as much space as necessary.


Please check those items that describe your child's alcohol or other drug use.

Other drinks that contain caffeine
Tobacco smoking products
Tobacco chewing products
Crack cocaine


Child's Interests and Strengths

Please describe your child's hobbies, interest and talents


Please describe your child's education or career interests


Please describe your child's strength, abilities and positive qualities.