Today's Date: Date CLIENT'S INFORMATIONName: First Name Last Name Date of Birth: Date* Sex Assigned at Birth: Pronouns you prefer: Type a label Demographics Please Select African-American Caucasian Latino/a/x Other Home Address: Street Address Address Line 2 City State Zip On Disability?: Yes No Employer/School: Name of EAP (if Applicable) Certification For EAP Authorization #: Number May we add your email address to our mailing list? Yes No Email: Email Telephone:Work: Area Code Phone Number Home: Area Code Phone Number Cell: Area Code Phone Number Release of Information Signed? Yes No INSURED INFORMATIONFull Name: First Name Last Name Date of Birth Date Relationship to Client: Address: Street Address Address Line 2 City State Zip Name of Insurance Company: I.D.# Group #
In the event of an emergency, who would we contact on your behalf?Name: First Name Last Name Telephone Number: Area Code Phone Number Relationship to you (if any): Address: Street Address Address Line 2 City State Zip
Medical Exam within:6 Months Yes No 12 Months Yes No If longer than 12 months, how long? Primary Care Physician:Name: Phone Number: Area Code Phone Number May I contact him/her? Yes No Current Medical Problems? Yes No Specify Problems:
Do you regularly sec a psychiatrist for medications? Yes No Psychotropic:Current Type: Dosage: Past Type: Dosage: Other:Current Type: Dosage: Past Type: Dosage: Compliance with Medication Yes No
Family History of:Psychiatric Diagnosis or Treatment?Family: Yes No Patient: Yes No Specify: Suicidal Attempts?Family: Yes No Patient: Yes No Specify: Homocidal Attempts?Family: Yes No Patient: Yes No Specify: Alcoholism?Family: Yes No Patient: Yes No Specify: Substance Abuse/Dependancy?Family: Yes No Patient: Yes No Specify: