• ADULT BEHAVIORAL HEALTH INTAKE FORM

  • Patient Demographics

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Contact Information

  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • INSURANCE INFORMATION

    Your insurance will not be billed at this time. This information is collected solely to verify your eligibility and benefits for services under your plan.
  • Do you plan on using insurance?*
  • Member's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Subscriber's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Reason(s) for Consultation

    Select All That Apply
  • Please select all the reasons for your consultation that apply to you from the list below. If you do not see your specific reason, select "Other" and specify under "Comments."
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  • Current Symptom(s)

    Please select all the current symptoms that apply to you from the list below. For each symptom selected, please provide the following details:
    • Duration: How long you have been experiencing the symptom
    • Frequency: How often you experience the symptom
    • Consequences: The effects or impact of the symptom on your daily life
    • Comments: Any additional details or context you wish to provide

    **If none of these symptoms apply, please select 'Not Applicable' and proceed to the next section.

  • Symptom(s) Checklist (select all that apply)
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  • Medical History

  • Do you have a Primary Care Provider?*
  • Primary Care Provider

  • Allergies

  • Do you have any known drug, environmental, or food allergies?*
  • List all known drug, environmental, or food allergies, your reaction, severity and when it occurred
  • Preferred Pharmacy*

  • Non-Psychiatric Medications

    If you are not currently taking any prescribed or over-the-counter medications, vitamins or supplements, proceed to the next section.
  • Please provide a list of all current non-psychiatric and OTC medications, dose & frequency including birth-control, supplements and vitamins.

  • Past Medical History

  • Please check the box if you have a history of any of the following medical conditions, and indicate whether the condition is active or resolved. Where applicable, provide details and your treatment course under 'Comments.' If none of these conditions apply, please select 'None of the Above' and proceed to the next section.
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  • Have you ever had a EKG?*
  • Was the EKG normal?

  • Request for EKG Results

    Skip this section if this does not apply to you
    • In order to continue your treatment with stimulant medication,  or if you are taking two or more antipsychotic medications, it is essential that we have a recent Electrocardiogram (EKG) result on file. This is to ensure your overall cardiac health and safety while using these medications.
    • If you have had an EKG within the last year, please upload a copy of the results below. If you do not have a recent EKG (less than 1 year old), we will need to schedule one.
    • This is a standard precaution to monitor any potential cardiac effects that can be associated with these types of medications. Your safety and health are our primary concern, and we appreciate your cooperation in providing this necessary information.
    • Please do not hesitate to contact our office if you have any questions or need assistance in scheduling your EKG.
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  • For women only:

  • Exercise Level

  • Do you exercise regularly?*
  • Do you have any concerns about your physical health that you would like to discuss with us?*
  • Birth History: When your mother was pregnant with you, were there any complications during the pregnancy or birth?*

  • SUICIDE RISK ASSESSMENT

  • In the past month, have you?
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  • Psychiatric History

  • Outpatient treatment*
  • Are you currently under the care of a psychiatric provider?*
  • Format: (000) 000-0000.
  • Do you currently have a therapist or counselor?*
  • Format: (000) 000-0000.
  • Please check all that apply if you have ever been diagnosed with any of the following psychiatric conditions. If you have never been diagnosed with any of these conditions, please select 'None - this is my first psychiatric contact' and proceed to the next section.
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  • Have you ever been hospitalized for psychiatric reasons?*
  • Personal history of suicide attempt, suicide ideation and/or self-harm*
  • History of Ketamine/Spravato treatment?*
  • History of ECT, TMS treatment?*

  • Trauma/Abuse History

    While this information helps us provide the best possible care, it is completely voluntary, and you may choose not to answer if you do not feel comfortable sharing at this time. All information will be kept strictly confidential.
  • Please select all the categories that apply to your personal history of trauma or abuse.
  • Are you currently taking any psychiatric medications?*

  • Current Psychiatric Medications

    If you are not currently taking any psychiatric medication, skip the next two sections. However, if you are, please provide a list of all current psychiatric medications you are taking.
  • For each medication, please include the following details:
  • Have you found any psychiatric medications to be effective, either in the past or currently?

  • Past Psychiatric Medications

    If you have never taken any of these medications, please select 'None of the Above' and proceed to the next section.
  • Check YES if you have ever taken any of the following medications. Please indicate the dose, frequency, treatment dates, efficacy, reason for stopping and side effects (if any).
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  • Substance Use History

  • Do you have a history of substance use?*

  • Please check YES if you have ever tried any of the substances listed below. For each substance selected, provide the following details:

    • First Use – The age when you first used the substance.
    • Frequency of Use – How often you used the substance (e.g., occasionally, weekly, daily).
    • Amount Used – The typical quantity or dose used (e.g., five drinks/day, 1 gram/day).
    • Route of Use – The method by which you used the substance (e.g., orally, intravenously, inhaled, smoked, snorted).
    • Last Use – When you last used the substance (e.g., last week, month, year).
    • Consequences of Use – Any significant outcomes or effects resulting from your use (e.g., health issues, legal troubles, relationship impacts).
  • Substance Use History
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  • Have you ever smoked cigarettes?*
  • If yes, please provide the following details:
  • History of substance or alcohol abuse treatment?*

  • ADHD Evaluation & Treatment History 

    Proceed to the next section if you are not seeking an ADHD evaluation
  • Do you have a confirmed ADHD/ADD diagnosis?
  • Have you ever had formal neuropsychological testing?
  • Date of testing
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have a copy of the evaluation? If yes, please provide a copy before your initial evaluation. If unavailable, request it to be sent to our clinic via fax at (617) 250-8262
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  • Have you ever been prescribed ADHD medication?

  • Family Background and Childhood History:

    Please note: The information gathered from these questions is confidential and used solely for the purpose of better understanding your background and informing your treatment. If any of these questions make you uncomfortable, you have the right to refuse to answer.
  • Were you adopted?*
  • Do you have any siblings?*
  • List your siblings name, age and gender from oldest to youngest
  • Did your parents divorce?*
  • Do you have any children? (adopted or biological)*
  • List each child from oldest to youngest*

  • Social History

  • Employment Status*

  • Family Medical History

  • Are you biological parents alive?*
  • Please check all that apply for both 1st and 2nd degree relatives with the following medical conditions. Indicate your relationship with the family member under "Relationship" and provide details under "Comments" where applicable. If none of these apply, please select "None of the Above" and move on to the next section.
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  • Family Psychiatric History

    This information is important as it can help us understand your potential health risks.
  • Please check all that apply for both 1st and 2nd degree relatives with the following psychiatric conditions. Indicate your relationship with the family member under "Relationship" and provide details under "Comments" where applicable. If none of these apply, please select "None of the Above" and move on to the next section
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  • Has anyone in your family (living or deceased) been diagnosed with or treated for any of the following psychiatric conditions? Please check all that apply for both 1st and 2nd degree relatives.*
  • Family History of Completed Suicide*

  • Treatment Authorization

    By providing my electronic signature below, I confirm that:
    • I hereby authorize Aspire Medical Group and its practitioners to provide mental health services, including evaluations and/or treatment for myself or the individual named above. 
    • I certify that I have read this form in its entirety and fully understand its contents. I have been given the opportunity to ask questions, and all of my questions have been answered to my satisfaction.
    • I have informed Aspire Medical Group of my medical history, including known allergies, current medications, supplements, and any past adverse reactions.
    • I accept the risks, conditions, and terms of the proposed treatment.
    • I acknowledge that my provider reserves the right to discontinue or adjust the treatment plan as necessary. Failure to comply with the terms of this agreement may result in discontinuation of treamtent. 
    • No guarantees have been made regarding the outcome of this treatment.
    • I certify that I have read this form, fully understand its contents, and have had all my questions answered.
    • I acknowledge that I am responsible for the payment of any services I receive.
    • To the best of my ability, I have provided complete and truthful information.
    • I have the right to be informed of the procedure, alternative options, and the associated risks and benefits.
    • I acknowledge that no guarantees have been made regarding the outcome of this treatment.
    • By signing this form, I voluntarily consent to treatment, agree to the use of electronic records and signatures, and confirm that I have the legal authority to be bound by this agreement. I voluntarily accept the risks, conditions, and terms outlined in this document.

  • Electronic Signatures

  • By providing my electronic signature below, I agree to the terms and conditions outlined in this agreement. I agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.

    The parties acknowledge and agree that this consent form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.

  • Effective Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • If the patient is a minor or is not legally competent to provide consent, the signature of a parent, guardian, or legal representative is required

  • Effective Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: