New Patient Intake form
for any fields that do not apply to you, please leave blank unless otherwise indicated.
What services are you seeking?
Please Select
psychiatry (medication management)
therapy
both
Contact Information
Patient name
First Name
Middle Name
Last Name
Preferred name:
Preferred pronouns:
Patient Birthday
-
Month
-
Day
Year
Date
If the person completing this form IS NOT the patient listed above, please provide you name and relation to the patient.
Patient Social Security number:
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
How do you prefer we communicate with you?
Please Select
Phone call
Text message
Email
Who is your insurance carrier? (ex: BCBS, Aetna, Soonercare). If you don’t have insurance, write self-pay.
File Upload
Browse Files
Drag and drop files here
Choose a file
Please upload a picture of the FRONT SIDE of your insurance card.
Cancel
of
File Upload
Browse Files
Drag and drop files here
Choose a file
Please upload a picture of the BACK SIDE of your insurance card.
Cancel
of
What pharmacy would you like us to send medication to? (Please provide name and address).
How were you referred to our clinic? (if you weren't referred, leave blank)
Tell us a bit about why you want to schedule an appointment:
Demographics
Please list your gender-identity (ex: male, female, non-binary, etc.)
Please list your sexual orientation:
Marital status:
Single
Married/long-term relationship
Divorced
Widowed
Partner's name and age:
Length of relationship?
Please list the people living in your home:
Please list any children with ages and where they reside:
What is your religious affiliation?
Are there any cultural/ethnic/spiritual considerations you would like us to know about?
What do you like to do in your free time/down time?
Do you have any issues making or keeping friends? (if no, write n/a).
Please list any past or ongoing legal issues:
Highest level of education:
Please Select
Did not complete high school
High school diploma/GED
Some college
Associate's degree
Technical degree
Bachelor's degree
Advanced degree
Current student
Did you deal with any of the following school related issues?
504 Plan/IEP
Skipped grades
Held back a grade
Expulsion
Occupational therapy
Speech therapy
Physical therapy
Suspension (in school)
Suspension (out of school)
Bullying
Require special help
Employment status:
Please Select
part-time
full-time
unemployed
disabled
student
What do you do for work? (if you don't work, write n/a).
Any past military experience? (if no, write n/a).
Medical History
Height:
Recent weight:
Date of last Physical Exam:
Please provide the name and number of your Primary Care Provider (write n/a if you don’t currently have one).
Have you or someone in your immediate family been diagnosed with any of the following:
Rows
Patient
Mom
Dad
Sibling
Child
Other
Anemia
Asthma
Cancer Leukemia
Cerebral Palsy
Diabetes
Down's Syndrome
Encephalitis
Epilepsy/seizures
Hearing Problems
Heart disease
HIV/AIDS
Hypertension
Loss of consciousness/head injury
Meningitis
Musculo-skeletal condition
Stroke
Thyroid Problems
Vision Problems
Dementia/Alzheimer's
Please list ANY OTHER serious and/or chronic illnesses you have (if none, write n/a):
Please list any past surgeries with approximate dates:
Are you sexually active?
If yes, what contraception method do you use?
Have you currently, or have you recently experienced any of the following symptoms:
Chills
Chronic pain
Blurred/double vision/vision change
Weight gain
Weight loss
Fever
Chest pain
Chest tightness
Lower extremity swelling
Sexual dysfunction
Incontinence
Fainting
Frequent headaches
Seizure
Eye pain
Chronic cough
Shortness of breath
Joint pain/swelling
Muscle pain
Heartburn
Itching
Sinus pressure/congestion/drainage
Sore throat
Skin lesions/rash/hives
Frequent constipation
Frequent diarrhea
Nausea
Vomiting
Cold or heat intolerance
Frequent urination
Any medication, food, or environmental allergies? What type of allergic reaction do you have? (write NKDA if none):
Please list all CURRENT NON-PSYCHIATRIC prescription medications, as well as any supplements, vitamins, or over-the-counter medications you take on a regular basis. Please include the strength and directions (ex: Lisinopril 10 mg every morning, Olly Sleep Gummy every night as needed for sleep.) If you are not on any medications, write n/a.
Behavioral Health History
Please list any CURRENT psychiatric medications, including medication strength and instructions (ex: Prozac 20 mg every morning). If you are not on any medications, write n/a.
Please list any PAST psychiatric medications including medication strength and response (ex: "worked well", "made my anxiety worse", "caused a rash"). If you have not been on any psychiatric medications before, write n/a.
Please list any PAST behavioral health care (inpatient, outpatient, psychological testing) along with approximate dates and provider names.
List any past suicide attempts or history of self-harm with dates.
If you are currently seeing therapy, please provider their name and office name.
Have you or someone in your family been diagnosed with any of the following:
Rows
Patient
Mom
Dad
Sibling
Child
Other
ADD/ADHD
Anxiety
Bipolar Disorder
Depression
DMDD
Eating Disorder
Encopresis/Enuresis
Hallucinations/Delusions/Paranoia
Learning/developmental disorder
OCD
ODD
Panic Attacks
Personality Disorder
PTSD
Schizophrenia
Substance Abuse/Dependency
Do you have any of the following sensory issues?
Overly sensitive to sounds
Light sensitivity
Texture issues
Coordination issues
Age of mother at time of birth?
Age of father at time of birth?
Did your mother use any of the following during pregnancy?
Alcohol
Cigarettes
Marijuana
Cocaine/crack
Opiates/Heroin
other illicit substances
How often do you exercise?
How would you describe your diet/eating habits?
Examples of typical diet:
Do you or have you smoked cigarettes?
Please Select
I have smoked, but do not currently.
I currently smoke.
i have never been a smoker.
Do you or have you used other forms of nicotine?
Please Select
Yes, I vape
Yes, I use chewing tobacco
No
Do you drink alcohol?
Please Select
Yes
Yes, and I think I drink too much
No, but I used to
No
Do you or have you consumed cannabis (marijuana)?
Please Select
yes
no, but I used to
no
Do you or have you used methamphetamines?
Please Select
Yes
Yes, but I don't anymore
No
Do you or have you used cocaine?
Please Select
Yes
Yes, but I don't anymore
No
Do you or have you used hallucinogens?
Please Select
Yes
Yes, but I don't anymore
No
Any other current or past substance use/abuse/dependency?
Submit
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