Patient Intake Form
Name
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Last Name
Today's Date
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Month
Day
Date
Date of Birth
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Day
Year
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SSN
Sex Assigned at Birth
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example@example.com
Whom may we thank for referring you?
Emergency Contact
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Primary Care Physician
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Allergies to Medications
Please List Current Medications
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Over the last 2 weeks, how often have you been bothered by the following problems?
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Not at all
Several Days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
Over the last 2 weeks, how often have you been bothered by the following problems?
Rows
Not at all
Several Days
More than half the days
Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
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My Products
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Psychiatric Evaluation
$450
$
450
Credit Card
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Submit
PHQ-9 Score (0-4 Minimal) (5-9 Mild) (10-14 Moderate) (15-19 Moderately-Severe) (20+ Severe)
GAD-7 Score (0-5 Minimal) (6-10 Mild) (11-15 Moderate) (16-21 Severe)
Should be Empty: