Name
*
Date of Birth
*
Phone Number
*
Home Address
*
Marital Status
*
Minor
Single
Married
Divorced
Separated
Emergency Contact Name and Phone Number
*
Source of Referral
*
Reason You Are Looking for Services
*
On (or applying for) any type of disability/workers comp (SSI/SSD):
*
Are you experiencing suicidal ideation?
*
Yes
No
Are you experiencing homicidal ideation?
*
Yes
No
Any current or past alcohol abuse?
*
Yes, current
Yes, past
No
Any current or past drug abuse?
*
Yes, current
Yes, past
No
Previous psychiatric hospitalizations?
*
Yes
No
If yes, please explain.
Comments:
Any legal history?
*
Yes
No
If yes, please explain.
Comments:
Are you looking for medication management, talk therapy, or both?
*
Who is your Primary Care Physician? Please include location and phone number.
*
Please list any medications you are currently taking (name, dose, and prescriber).
*
Primary Insurance
*
Insurance ID number
*
Insurance Group number
*
Name of Primary Insurance Card Holder
*
Primary Card Holder Date of Birth
*