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General Information
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Name
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Address:
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Contact phone number
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Date of Birth?
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Email Address
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Psychiatric History
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Current Psychiatric Diagnosis
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Additional Comments
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Current Psychiatric Medications and doses
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Prior Psychiatric Medications and dates?
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Additional Comments
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History of Psychiatric Hospitalizations?
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New Yes / No
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Additional Comments if necessary
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History of Suicidal Thoughts?
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Current Suicidal Thoughts?
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History of suicide attempts or self-harm? If so, list dates.
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History of Substance Use Treatment?
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Additional Substance Treatment info
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Last Psychiatric Provider?
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Additional Comments if necessary
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Family Psychiatric History? If so, please specify.
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Are you currently seeing a therapist? If so, please list name and frequency of visits.
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Past history of seeing a therapist? If so, please list dates.
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Medical History
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Current or Prior Medical Diagnosis?
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Additional Comments if necessary
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Allergies (medication/food)?
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Current over the counter supplements, vitamins or medications prescribed by another doctor.
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Significant Family Medical History
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Please list family medical history (including stroke, Heart attack, diabetes etc).
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Social History
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Where were you born and raised?
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Do you have siblings?
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What are the ages of your siblings?
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Highest Level of Education?
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Are you currently employed? Full time? Part time? Other?
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What is your occupation?
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Single/Married/Divorced/Partnered?
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Were you married previously? If so, when?
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Do you have any children? If so, what are their ages?
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History or Emotional/Sexual/Physical Abuse
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Have you ever been arrested? If yes, when?
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Additional Comments if necessary
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Have you ever served in the military?
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Surgical History?
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Procedure/Date?
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Additional Comments if necessary
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Insurance Info
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Insurance name
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Insurance ID/Group Number
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Preferred Pharmacy
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Name/Address
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Pharmacy Phone
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ADDITIONAL INFORMATION
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Where did you find us?
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Who referred you?
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Which specialists do you see?
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Do you use online scheduling?
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Want access to online portal?
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Anything special we need to know
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Credit Card Information for File
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Credit Card Number
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Exp Date
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CVC
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Billing Zip Code
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USE CARD FOR?
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