Identification
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Primary Insurance Card
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Front and back
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Secondary Insurance card
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Demographics
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred method of communication
*
Please Select
Text
Phone call
Email
Preferred pronoun(s)
Please Select
He/him/his
She/her/hers
They/them/theirs
Other
Who is this questionnaire being completed for?
*
Please Select
Self
Child
Spouse
Friend
How did you hear about us?
*
Please Select
Google My Business
Psychology Today
Website
Referred by PCP
Referred by counselor/therapist
Friend/Colleague/Peer
If referred, then by whom?
Goals of Care
What diagnoses are you interested in being evaluated for?
*
What treatment options are you open to discussing?
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Continuing stable treatment regimen
New medications/ treatments
No medications, counseling only
Both medications and counseling
Neither (only a consultation or second opinion)
Are you seeking a new evaluation for any of the following cases? Check all that apply.
Work injury/worker's compensation case
Short term disability
Long term disability
Child/adult protection case
Other legal case
None of the above
How many psychiatrists have you worked with in the past?
*
Please Select
None
1 to 2
3 to 4
More than 5
If transferring from another psychiatrist, what are your reasons for the change?
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Job/ Insurance changed
Doctor moved/retired
Relocated
Dissatisfied with front office staff
Dissatisfied with clinical care
Can't get refills in time
Not transferring
Other
Mental Health History
Please select any and all pre-existing diagnoses. Check all that apply.
*
ADHD
Alcohol Abuse
Anorexia
Autism
Generalized Anxiety
Binge Eating Disorder
Benzodiazepine Use Disorder
Bipolar I Disorder
Bipolar II Disorder
Borderline Personality Disorder
Bulimia
Dementia
Intellectual Developmental Disability
Obsessive Compulsive Disorder
Eating Disorder
Excessive Daytime Sleepiness
Hypochondria
Impluse Control
Insomnia/Circadian Rhythm Disorder
Major Depression
Narcolepsy
Opioid Use
Panic Disorder
Phobias
Postpartum Depression
Prescription Medication Abuse
PTSD
Schizophrenia
Seasonal Depression
Separation Anxiety
Social Anxiety
Stimulant Abuse
Tobacco Abuse
None
Please list all psychiatric medications you are (supposed to be) on.
*
If none put N/A
List past medication trials. Include the name, dosage, reason for discontinuation.
*
If none put N/A
Are you currently in therapy?
*
Please Select
yes
no
If yes, please list your therapist and therapy modality, if known. Otherwise, put N/A
*
Have you ever needed a higher level of care such as any of the following?
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Psychiatric ER visits
Emergency detention warrants
Psychiatric inpatient hospitalization
Intensive outpatient treatment program
Partial hospitalization program
Detox
None
If "yes", please explain. List all dates, circumstances, and any interventions.
*
If none put N/A
Please describe your alcohol use (frequency, quantity, thinking/trying to quit or not)
If none put N/A
Please describe your alcohol use (frequency, quantity, thinking/trying to quit or not)
*
If none put N/A
Please describe your tobacco/nicotine use (frequency, quantity, thinking/trying to quit or not)
*
If none put N/A
Please describe your recreational drug use (frequency, quantity, thinking/trying to quit or not). This includes any cannabis, opioids (heroin, fentanyl, prescription painkillers), stimulant (cocaine, meth, synthetic THC, ADHD meds without a prescription), psychedelics.
*
If none put N/A
Please select any recreational substances used for any reason. Check all that apply.
Alcohol
Tobacco
Nicotine vapes
Cannabis
Synthetic marijuana
Methamphetamine
Cocaine
Heroin
Fentanyl
Psychedelics
Prescription Painkillers
None
Do you have a history of any of the following behaviors or symptoms? Check all that apply.
Auditory hallucinations
Visual hallucinations
Feelings of being tracked/followed
Self-harm or self-injury
Suicide attempts
Dissociation
None
Suicide Risk Assessment
Have you ever thought about or attempted to end your life?
*
Please Select
Never
It was just a brief passing thought
I have had a plan at least once but did not try to do it
I have had a plan at least once and really wanted to die
I have attempted but did not want to die
I have attempted and really hoped to die
How often have you thought about ending your life in the past year?
*
Please Select
Never
Rarely (1 time)
Sometimes (2 times)
Often (3-4 times)
Very Often (5 or more times)
Have you ever told someone that you might or were going to commit suicide?
*
Please Select
Never
Yes, at one time, but did not really want to die
Yes, at one time, and really wanted to die
Yes, more than once, but did not want to do it
yes, more than once, and really wanted to do it
How likely is it that you will attempt suicide someday?
*
Please Select
Never
Unlikely
Likely
Very likely
Patient Care Improvement
In certain situations, such as complex medical histories, past medical/psychiatric hospitalizations, and refilling controlled substances, we encourage medical records in advance of the initial visit. Will you be able to provide these?
*
Please Select
Yes
No
Your follow-up visits are determined based on your history, severity of symptoms, and anticipated clinical course. Earlier follow-ups may be 2 to 4 weeks apart and transition to either monthly or every 2 to 3 month visits. What are your thoughts on the frequency of follow-ups for medication management?
*
Please Select
I defer the frequency to my treating physician
I strongly prefer visits every two to four weeks; anything more I worry about destabilizing
I do not ever wish to meet more than once a month and am comfortable with calling the office with any interim questions.
For medication purposes
*
18 and under please put your height and weight. If over 18 please put N/A.
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