Common use of Family History Clause in Contracts

Family History. Where was the patient born? Where did the patient grow up? City Suburbs Country Please list the patient’s parents, step-parents, siblings, and any other significant family members. Please use additional space on the back if needed. Name Age Relationship Where do they live now? If deceased, age and cause of death Who has the patient lived with throughout their childhood? Mother's occupation: Father's occupation? In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc). Condition Please Circle List Family Member Alcohol/ Substance Abuse Yes / No Anxiety Yes / No Depression Yes / No Domestic Violence Yes / No Sexual Abuse Yes / No Eating Disorders Yes / No Obesity Yes / No Obsessive Compulsive Disorder Yes / No Schizophrenia Yes / No Suicide Attempts Yes / No Other diagnosed mental health condition? Yes / No: Which was?: Guardians’ Marital Status: Primary Guardian #1 (PG#1) / Primary Guardian#2 (PG#2) PG#1 / PG#2 Never Married Domestic Partner Married **If married, how long have you been married, and what is your partner’s name: (PG#1) (PG#2) Separated Divorced -- For how long? Widowed: Please provide your partners name and year deceased: (PG#1 or PG#2?-Circle) *Parent(s) currently in a romantic relationship? Yes -- How long? (PG#1) No (PG#2) What is the patient’s Gender? Preferred pronoun(s)? What is the patient’s Sexual Orientation? Any issues related to gender or sexual orientation that might be relevant to treatment? Physical Health Please list any medications, herbs, or supplements. Be sure to include the condition, as some medications are prescribed for off-label use. Continue on the back if needed, or provide a separate list. If your child has a complicated medical profile, please supply supporting documentation to be able to facilitate a comprehensive understanding of your child’s health. Medication/Supplement Dosage Condition Date Began/Stopped Prescribing provider(s) and contact information: Name: Specialty: Facility: Phone, email, or Fax: How would you rate the patient’s current physical health? Poor Unsatisfactory Satisfactory Good Very Good Please list any specific and significant health problems the patient is currently experiencing: How would the patient rate their current sleeping habits? Poor Unsatisfactory Satisfactory Good Very Good If the patient is having problems, in which phase of sleep are they experiencing issues? Falling asleep Staying asleep Awakening early Sleep apnea Please list any other specific sleep problems the patient is currently experiencing: How many times per week does the patient generally exercise? What types of exercise does the patient participate in?: Is the patient currently experiencing any chronic pain? No Yes If yes, please describe: Substance Use/ Abuse Please describe current use of alcohol, cigarettes, and/or recreational drugs: Please describe previous use of alcohol, cigarettes, and/or recreational drugs: Additional Information Describe the patient’s strengths and limitations related to education: Is there an IEP/504 Plan? Yes No Describe the patient’s social relationships: What does the patient enjoy doing in their free time? What do they do to relax? Is the patient spiritual or religious? If yes, please describe their faith or belief: What are some of the patient’s strengths? What are some of the patient’s weaknesses? Any additional Information that might help your child’s clinician better understand your child’s unique circumstances: Reviewed by (Therapist/Supervisor): Print Signed Date *See biopsychosocial assessment for additional notes* Phone: (833) ETC-LIFE Email: xxxx@xxxxxxxxxxxxxxx.xxx 0000 Xxxxxxx Xx, Xxxxx 000 Manassas, VA 20110 Patient Acknowledgement Receipt of Patient Agreement Please sign, print your name, and date this acknowledgement form. By signing below, I hereby acknowledge that I have been provided with the Empowerment Therapy Center’s (ETC’s)

Family History. Where was the patient born? Where did the patient grow up? City Suburbs Country Please list the patient’s parents, step-parents, siblings, and any other significant family members. Please use additional space on the back if needed. Name Age Relationship Where do they live now? If deceased, age and cause of death Who has the patient lived with throughout their childhood? Mother's occupation: Father's occupation? In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc). Condition Please Circle List Family Member Alcohol/ Substance Abuse Yes / No Anxiety Yes / No Depression Yes / No Domestic Violence Yes / No Sexual Abuse Yes / No Eating Disorders Yes / No Obesity Yes / No Obsessive Compulsive Disorder Yes / No Schizophrenia Yes / No Suicide Attempts Yes / No Other diagnosed mental health condition? Yes / No: Which was?: Guardians’ Marital Status: Primary Guardian #1 (PG#1) / Primary Guardian#2 (PG#2) PG#1 / PG#2 Never Married Domestic Partner Married **If married, how long have you been married, and what is your partner’s name: (PG#1) (PG#2) Separated Divorced -- For how long? Widowed: Please provide your partners name and year deceased: (PG#1 or PG#2?-Circle) *Parent(s) currently in a romantic relationship? Yes -- How long? (PG#1) No (PG#2) What is the patient’s Gender? Preferred pronoun(s)? What is the patient’s Sexual Orientation? Any issues related to gender or sexual orientation that might be relevant to treatment? Physical Health Please list any medications, herbs, or supplements. Be sure to include the condition, as some medications are prescribed for off-label use. Continue on the back if needed, or provide a separate list. If your child has a complicated medical profile, please supply supporting documentation to be able to facilitate a comprehensive understanding of your child’s health. Medication/Supplement Dosage Condition Date Began/Stopped Prescribing provider(s) and contact information: Name: Specialty: Facility: Phone, email, or Fax: How would you rate the patient’s current physical health? Poor Unsatisfactory Satisfactory Good Very Good Please list any specific and significant health problems the patient is currently experiencing: How would the patient rate their current sleeping habits? Poor Unsatisfactory Satisfactory Good Very Good If the patient is having problems, in which phase of sleep are they experiencing issues? Falling asleep Staying asleep Awakening early Sleep apnea Please list any other specific sleep problems the patient is currently experiencing: How many times per week does the patient generally exercise? What types of exercise does the patient participate in?: Is the patient currently experiencing any chronic pain? No Yes If yes, please describe: Substance Use/ Abuse Please describe current use of alcohol, cigarettes, and/or recreational drugs: Please describe previous use of alcohol, cigarettes, and/or recreational drugs: Additional Information Describe the patient’s strengths and limitations related to education: Is there an IEP/504 Plan? Yes No Describe the patient’s social relationships: What does the patient enjoy doing in their free time? What do they do to relax? Is the patient spiritual or religious? If yes, please describe their faith or belief: What are some of the patient’s strengths? What are some of the patient’s weaknesses? Any additional Information that might help your child’s clinician better understand your child’s unique circumstances: Reviewed by (Therapist/Supervisor): Print Signed Date *See biopsychosocial assessment for additional notes* Phone: (833) ETC-LIFE Email: xxxx@xxxxxxxxxxxxxxx.xxx 0000 Xxxxxxx Xx, Xxxxx 000 Manassas, VA 20110 Patient Acknowledgement Receipt of Patient Agreement Please sign, print your name, and date this acknowledgement form. By signing below, I hereby acknowledge that I have been provided with the Empowerment Therapy Center’s (ETC’s).

Family History. Where Parents (Any history of inherited disorders eg. asthma, hear problems, learning difficulties etc): Learner concerned ( Any inherited disorders eg. asthma, heart problems, learning difficulties etc): Siblings ( Any inherited disorders eg. asthma, heart problems, learning difficulties etc): Extended family ( Any inherited disorders eg. asthma, heart problems, learning difficulties etc): OBSTETRICAL HISTORY Did you have difficulty falling pregnant? Did you have miscarriages before falling pregnant? How old were you when you fell pregnant? What was the patient bornmoms general state of health during pregnancy eg viral infections, illness, German Measles, stress, excessive morning sickness, haemorrhage? Were any prescription drugs taken during your pregnancy? Where did there any blood type complications during your pregnancy? What was duration of pregnancy? Were there any complication relating to the patient grow upbirth? City Suburbs Country Please list NEONATAL PERIOD Birth Weight? Breast or Bottle fed? Where there any feeding problems: Were there any difficulties introducing solids? Developmental Milestones First smile: Held head up first time: Sat unaided: Stood unaided: Crawled: Walked unaided: Began babbling: First words: Sentences: Understanding and response to commands: MEDICAL HISTORY Has your child had any significant illnesses? Has your child ever been in hospital (if yes please give a brief description)? Has your child experienced any recurrent illnesses (eg. ear/nose throat infections)? Does your child have a history of seizures, convulsions or epilepsy? Is your child on any medication at present (if yes supply name and dosage)? Is your child currently attending any therapies? (If yes please supply therapist name and contact number) Is your child’s immunizations up to date? Does your child have any allergies? Does your child have any physical / coordination difficulties? Does your child have any visual / hearing difficulties? SOCIAL EMOTIONAL DEVELOPMENT Describe the patient’s parents, step-parents, siblings, and any other significant relationship your child has with immediate family members. : Describe any behavioral or emotional difficulties your child may have: How would you describe your child’s personality? Please use additional space on the back indicate if needed. Name Age Relationship Where do they live now? If deceased, age and cause of death Who your child has the patient lived difficulties with throughout their childhood? Mother's occupation: Father's occupation? In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc). Condition Please Circle List Family Member Alcohol/ Substance Abuse Yes / No Anxiety Yes / No Depression Yes / No Domestic Violence Yes / No Sexual Abuse Yes / No Eating Disorders Yes / No Obesity Yes / No Obsessive Compulsive Disorder Yes / No Schizophrenia Yes / No Suicide Attempts Yes / No Other diagnosed mental health condition? Yes / No: Which was?Sleeplessness: Guardians’ Marital StatusTactile Defensive: Primary Guardian #1 (PG#1) / Primary Guardian#2 (PG#2) PG#1 / PG#2 Never Married Domestic Partner Married **If married, how long have you been married, and what is your partner’s nameAuditory Defensive: (PG#1) (PG#2) Separated Divorced -- For how long? WidowedOral Sensitivity: Please provide your partners name and year deceasedSelf Stimulatory Behavior’s: (PG#1 or PG#2?-Circle) *Parent(s) currently in a romantic relationship? Yes -- How long? (PG#1) No (PG#2) What is the patient’s Gender? Preferred pronoun(s)? What is the patient’s Sexual Orientation? Any issues related to gender or sexual orientation that might be relevant to treatment? Physical Health Please list any medications, herbs, or supplements. Be sure to include the condition, as some medications are prescribed for off-label use. Continue on the back if needed, or provide a separate list. If your child has a complicated medical profile, please supply supporting documentation to be able to facilitate a comprehensive understanding of your child’s health. Medication/Supplement Dosage Condition Date Began/Stopped Prescribing provider(s) and contact information: Name: Specialty: Facility: Phone, email, or Fax: How would you rate the patient’s current physical health? Poor Unsatisfactory Satisfactory Good Very Good Please list any specific and significant health problems the patient is currently experiencing: How would the patient rate their current sleeping habits? Poor Unsatisfactory Satisfactory Good Very Good If the patient is having problems, in which phase of sleep are they experiencing issues? Falling asleep Staying asleep Awakening early Sleep apnea Please list any other specific sleep problems the patient is currently experiencing: How many times per week does the patient generally exercise? What types of exercise does the patient participate in?: Is the patient currently experiencing any chronic pain? No Yes If yes, please describe: Substance Use/ Abuse Please describe current use of alcohol, cigarettes, and/or recreational drugs: Please describe previous use of alcohol, cigarettes, and/or recreational drugs: Additional Information Describe the patient’s strengths and limitations related to education: Is there an IEP/504 Plan? Yes No Describe the patient’s social relationships: What does the patient enjoy doing in their free time? What do they do to relax? Is the patient spiritual or religious? If yes, please describe their faith or belief: What are some of the patient’s strengths? What are some of the patient’s weaknesses? Any additional Information that might help your child’s clinician better understand your child’s unique circumstances: Reviewed by (Therapist/Supervisor): Print Signed Date *See biopsychosocial assessment for additional notes* Phone: (833) ETC-LIFE Email: xxxx@xxxxxxxxxxxxxxx.xxx 0000 Xxxxxxx Xx, Xxxxx 000 Manassas, VA 20110 Patient Acknowledgement Receipt of Patient Agreement Please sign, print your name, and date this acknowledgement form. By signing below, I hereby acknowledge that I have been provided with the Empowerment Therapy Center’s (ETC’s)Easily Frightened:

Family History. Where was the patient born? Where did the patient grow up? City Suburbs Country Please list the patientMother’s parents, step-parents, siblings, and any other significant family members. Please use additional space on the back if needed. Name Age Relationship Where do they live now? age: If deceased, age and cause how old were you when she died? Father’s age: If deceased, how old were you when he died? If your parents are separated or divorced, how old were you then? Number of death Who has the patient lived with throughout their childhood? Mother's occupation: Father's occupation? In the section below identify if there is brother(s) Their ages Number of sister(s) Their ages I was child number in a family history of any children. Were you adopted or raised with parents other than your natural parents? Yes No Briefly describe your relationship with your brothers and/or sisters: Which of the following. If yes, please indicate following best describes the family memberin which you grew up? WARM AND HOSTILE AND ACCEPTING AVERAGE FIGHTING 1 2 3 4 5 6 7 8 9 Which of the following best describes the way in which your family raised you? ALLOWED ME TO BE VERY ATTEMPTED TO YOUR MOTHER (or mother substitute) Briefly describe your mother: _ How did she discipline you? How did she reward you? How much time did she spend with you when you were a child? much average little Your mother’s relationship to occupation when you in the space provided were a child: stayed home worked outside part-time worked outside full-time How did you get along with your mother when you were a child? poorly average well How do you get along with your mother now? poorly average well Did your mother have any problems (fathere.g., grandmotheralcoholism, uncleviolence, etc). Condition Please Circle List Family Member Alcohol/ Substance Abuse Yes / No Anxiety Yes / No Depression Yes / No Domestic Violence Yes / No Sexual Abuse Yes / No Eating Disorders Yes / No Obesity Yes / No Obsessive Compulsive Disorder Yes / No Schizophrenia Yes / No Suicide Attempts Yes / No Other diagnosed mental health condition.) that may have affected your childhood development? Yes / No: Which was?: Guardians’ Marital Status: Primary Guardian #1 (PG#1) / Primary Guardian#2 (PG#2) PG#1 / PG#2 Never Married Domestic Partner Married **If married, how long have you been married, and what is your partner’s name: (PG#1) (PG#2) Separated Divorced -- For how long? Widowed: Please provide your partners name and year deceased: (PG#1 or PG#2?-Circle) *Parent(s) currently in a romantic relationship? Yes -- How long? (PG#1) No (PG#2) What is the patient’s Gender? Preferred pronoun(s)? What is the patient’s Sexual Orientation? Any issues related to gender or sexual orientation that might be relevant to treatment? Physical Health Please list any medications, herbs, or supplements. Be sure to include the condition, as some medications are prescribed for off-label use. Continue on the back if needed, or provide a separate list. If your child has a complicated medical profile, please supply supporting documentation to be able to facilitate a comprehensive understanding of your child’s health. Medication/Supplement Dosage Condition Date Began/Stopped Prescribing provider(s) and contact information: Name: Specialty: Facility: Phone, email, or Fax: How would you rate the patient’s current physical health? Poor Unsatisfactory Satisfactory Good Very Good Please list any specific and significant health problems the patient is currently experiencing: How would the patient rate their current sleeping habits? Poor Unsatisfactory Satisfactory Good Very Good If the patient is having problems, in which phase of sleep are they experiencing issues? Falling asleep Staying asleep Awakening early Sleep apnea Please list any other specific sleep problems the patient is currently experiencing: How many times per week does the patient generally exercise? What types of exercise does the patient participate in?: Is the patient currently experiencing any chronic pain? No Yes If yes, please describe: Substance Use/ Abuse Please describe current use of alcohol, cigarettes, and/or recreational drugs: Please describe previous use of alcohol, cigarettes, and/or recreational drugs: Additional Information Describe the patient’s strengths and limitations related to education: ) Is there an IEP/504 Plananything unusual about your relationship with your mother? Yes No Describe the patient(If Yes, please describe) YOUR FATHER (or father substitute) Briefly describe your father: How did he discipline you? How did he reward you? How much time did he spend with you when you were a child? much average little Your father’s social relationshipsoccupation when you were a child: What does the patient enjoy doing in their free timestayed home worked outside part-time worked outside full-time How did you get along with your father when you were a child? What poorly average well How do they do to relaxyou get along with your father now? Is the patient spiritual or religiouspoorly average well Did your father have any problems (e.g. alcoholism, violence, etc.) that may have affected your childhood development? Yes No (If yes, please describe their faith or belief: What are some of the patient’s strengthsdescribe) Is there anything unusual about your relationship with your father? What are some of the patient’s weaknesses? Any additional Information that might help your child’s clinician better understand your child’s unique circumstances: Reviewed by No Yes (Therapist/Supervisor): Print Signed Date *See biopsychosocial assessment for additional notes* Phone: (833) ETC-LIFE Email: xxxx@xxxxxxxxxxxxxxx.xxx 0000 Xxxxxxx XxIf yes, Xxxxx 000 Manassas, VA 20110 Patient Acknowledgement Receipt of Patient Agreement Please sign, print your name, and date this acknowledgement form. By signing below, I hereby acknowledge that I have been provided with the Empowerment Therapy Center’s (ETC’splease describe)