New Patient Packet

Patient Full Name

First NameLast Name
Birth Date

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Sex
Primary Insurance Information
Do You Have a Secondary Insurance Policy?
Secondary Insurance Information
Emergency Contact(s)
Do You Have a Surrogate/Legal Guardian?
Surrogate/ Legal Guardian Information
Picture

We are a medical facility committed to reducing the risk of medical errors. We need a passport-style picture to identify your medical record properly. Please take a passport-style photo. Please note, you will not be able to submit this form without a valid photo.
Take Photo:
We will need copies of the front/back of your government issued ID and of your insurance card(s).

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Family History
Has anyone in your family been diagnosed with a behavioral health disorder (like Depression/OCD/Anxiety) or substance abuse disorder (suspected or diagnosed)?If yes, explain which family member and what disorder?
Has anyone, blood related to you, attempted or completed suicide? If yes, please indicate family relationship and year of incident:

Rows	Not At All	Several Days	More Than Half the Days	Nearly Every Day
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling asleep, staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you're a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or, the opposite - being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way

Rows	Not At All	Several Days	More Than Half the Days	Nearly Every Day
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

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