She's Counseling Medication Management Intake Form

She's Counseling Medication Management Intake Form

Private Insurance
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Age*
Gender*

FemaleMale
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Insurance companies*

Healthy ConnectionsBCBSHealthy BlueBlue OptionsBlue EssentialsSC State Health PlanPreferred BlueMolinaMedicare AdvantageOptumTricareSC MedicareUnited Health Care
Insurance Number*
Insurance Card (Front)
Insurance Card (End)
Check all symptoms that apply*

Sad/depressed moodLoss of interest/pleasureFeeling worthless/guiltWithdrawn/Social IsolationIrritability/outbursts of angerWeight gain/lossAppetite increase/decreaseSleep disturbanceCrying spellsDifficulty concentratingInflated self-esteemGrandiosityTalkativeFlight of ideasDistractibilityUnrestrained buying spreesSexual indiscretionsExcessive pleasure activitiesMuscle tensionHeart palpitationsSweating not due to heatTrembling/shakingShortness of breathFeeling of chokingChest pain/discomfortFeeling dizzy/lightheadedCompulsionsFear of losing controlRecurrent/persistent thoughtsRecurrent/intrusive memoriesLaxative/diuretic abuseTrouble following directionsTouchy/easily annoyedThoughts of SuicideHomicidal IdeationPoor impulse controlRelationship difficultiesDeliberate property destructionOther
Reason for Medication Managment*
List any chronic health problems you may have
List out all current medication
List out allergies
Have you received any outpatient treatment for a psychiatric condition ?

YesNo
Have you been hospitalized?

YesNo
Please select the option that apply regarding your smoking habits

None0 -1 package a day1 - 2 packages a day2+ packages a day
Average # alcoholic drinks per week?
Average hour of sleep per week?
Average # of workouts per week?
Date

MonthDayYear
Date
Signature

Clear
Therapist Requested

First NameLast Name
Should be Empty: