|
1. Unit of treatment
|
*Referring Clinician/Friend
|
|
2. How did you hear about us?
• • •
|
|
|
3. What brings you in for therapy now?
|
*Explanation
|
|
4. Have you ever been suicidal?
• • •
|
*Explanation
|
|
5. Has your PARTNER ever been suicidal?
• • •
|
*Explanation
|
|
6. Have YOU ever intentionally harmed yourself?
|
*Explanation
|
|
7. Has PARTNER ever intentionally harmed self?
|
*Explanation
|
|
8. Felt physically unsafe in a relationship?
|
*Explanation
|
|
9. History of violence?
|
*Explanation
|
|
10. Experienced hallucinations?
|
*Name, duration, explanation
|
|
11. Hospitalizations for psych reason?
|
For PARTNER, how many drinks per week?
|
|
12. How many drinks per week?
|
Pot, how much PARTNER smokes per month?
|
|
13. Smoking pot, how often per month?
|
*PARTNER Alcohol/drug use description
|
|
*Alcohol/drug use description
|
*Explanation (providers' name + duration)
|
|
14. Previous therapy?
|
*Explanation (providers' name + duration)
|
|
15. Previous Psychiatric care?
|
Name of medication(s), duration, dosage
|
|
16. Psychiatric or other medications?
|
name of medical condition
|
|
17. Previous or current medical condition(s)?
|
*Explanation
|
|
19. Occupation
|
20. Anything special we need to know?
|
|
|
22. Availability for sessions
• • •
|
|
Inform patient of fee
|
23. Availability specifics
|
|
If intern what is their combined yearly income?
|
Inform patient of CX policy (2 Business Days)
|
|
Name on credit card
|
Fee quoted
|
|
Credit card number
|
|
|
Credit card expiration date
/
|
Credit card type
|
|
Can you send us past mental health records?
|
Credit card security code
|
|
Would you like to receive Well updates via emai?
|
Credit Card Billing zip code
|
|
Do you use online scheduling?
|
Would you like access to our patient portal?
|
|
permission to record and store CC information
|
email address:
|
|
informed communication via email is not secure
|
|
