Mental Health Intake Form
Patient's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Gender
*
Please Select
Male
Female
Other
Who referred you, or how did you find out about us?
*
APPOINTMENT LOCATION
Preferred Appointment Location
*
TELEHEALTH
Winston Salem: 8025 N Point BLVD Suite 217 Winston Salem NC 27106
Greensboro: 109 Muirs Road Chapel Suite 123 Greensboro NC 27410
FIRST AVAILABLE _ ANY LOCATION
TREATMENT YOU ARE SEEKING
Treatment of Choice
*
MEDICATION MANAGEMENT
THERAPY
BOTH MED MANAGEMENT AND THERAPY
NOT SURE YET, GUIDE ME
HEALTH HISTORY
HEIGHT & WEIGHT
*
Height in feet
Weight in lbs
Allergies? (If yes, please list them with the reactions)
*
Reason for seeking appointment
*
CURRENT DIAGNOSIS
*
ACTIVE MEDICATIONS
*
Click here to upload any medical or lab record(s) you may have.
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INSURANCE DETAILS
*
Insurance Front
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Insurance Back
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Government ID Front
*
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Government ID Back
*
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Face Photo (Smile)
*
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SAFETY ASSESSMENT
Do you currently have thoughts of ending your life?
*
Please Select
Yes
No
If yes, describe.
SUBSTANCE USE HISTORY
Check if you currently use any of the following:
*
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
None
Other
Name of the person completing this form (If other than self).
Preferred Pharmacy
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is there anything else you'll want us to know?
Please Select
Signature
*
Submit
Should be Empty: