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General Information
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New Patient Intake Forms
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Patient Name
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Last Name
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Middle Name
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Preferred Name
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Sex
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Pronouns
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Date of birth
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Email Address
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Social Security Number
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Primary Phone
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Cell Phone
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Address
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City
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State
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Zip Code
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Referred by (name of therapist/referral source)
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Reason for Referral
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Emergency Contact Name (First, Last)
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Relationship to Patient
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Emergency Contact Phone
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Name of Preferred Pharmacy and Address, including zipcode
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Preferred Pharmacy Phone
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Do you have insurance?
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Payment responsibility
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Insurance Company
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Insurance Type
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Policy Holder Name
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Phone
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Address
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Subscriber ID
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Policy Holder Date of Birth
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Group #
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Insurance Card Photo Upload
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Do you have Secondary Insurance?
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Is this a worker's compensation claim?
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Primary Care Provider
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Date of last physical
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Patient Name
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Patient/Client Signature
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Date
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Valid Photo ID Required
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New Short Text Field
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Health History
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1. Can you please tell me what you are seeking care for?
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2. What healthcare goals do you hope to achieve in seeing one of our providers?
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Are you CURRENTLY having thoughts of harming yourself?
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If no, are you going to be able to keep yourself safe?
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Are you CURRENTLY having thoughts of harming others?
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Are you currently taking any PSYCHIATRIC medications?
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**For TM patients: Please note that you will need to be seen in-person at least once in order for your provider
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Medication/ Daily Dosage/ Frequency/ Are you taking as prescribed?
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A.
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Medication Concerns?
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Medication helpful?
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B.
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Medication Concerns?
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Medication helpful?
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C.
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Medication Concerns?
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Medication helpful?
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Have you taken psychiatric medication in the past?
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Medication/ Daily Dosage/ Frequency/ Are you taking as prescribed?
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A.
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Medication helpful?
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I took this medication in the past
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B.
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Medication Concerns?
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Medication helpful?
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C.
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Medication Concerns?
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Medication helpful?
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I took this medication in the past
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Other medications you have taken in the past
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In-office appointments will be required upon initiation of a controlled medication and then at least once every two years or soo
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Please list allergies here
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Do you have any allergies to medication?
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height
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weight
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Social History
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Developmental History
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Where did you grow up?
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What was your childhood like? (happy, chaotic, etc)
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Who lived with you?
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Please describe your parents and siblings and provide a brief statement about your relationship
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Parents
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Siblings
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Educational History
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Are you currently in school?
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What school do you attend?
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What grade are you in or will be entering into?
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Do you enjoy school or is there anything stressful about school?
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Highest level of education completed
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Mark all that apply about your education:
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Employment History
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What is your occupation?
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What do you like and dislike about your job?
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Personal Social History
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Please list two people you feel you can count on if you are having a difficult time
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Social factors (check all that apply)
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Safety
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I feel safe at home and in my relationships
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I drive / ride in cars with intoxicated drivers
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I own or have access to firearms
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I consume caffeine, alcohol, nicotine, etc
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Please list any specific health problems you are currently experiencing
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Please list any specific sleep problems you are currently experiencing
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Have you recently had any of these symptoms?
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Constitutional
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HEENT
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Cardiovascular
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Respiratory
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GI
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Skin
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Urinary
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Sexual Health-Females
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Sexual Health-Males
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Endocrine
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Neurological
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Musculoskeletal
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Coordination of Care
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Have you ever seen a psychiatrist before?
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If yes, name & last visit:
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Have you ever seen a therapist before?
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*If yes, name & last visit:
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Medical History
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New Multiple Have you ever been diagnosed or treated for any of the following?Select
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Family Medical History
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Has any family member or relative ever been diagnosed or treated for any of the following?
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