New Patient Intake Form
Name
*
First Name
Last Name
Preferred Phone
*
Date of Birth
*
/
Month
/
Day
Year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Whom may we thank for you referral?
*
Sex Assigned at Birth
*
Male
Female
Prefer not to respond
Gender Identity
Sexual Orientation
Preferred Language
Preferred Name
Ethnicity
Race
Religion (If Applicable)
Provider Preferences
*
Scheduling Preferences
*
Insurance
Name of Primary Insured (Subscriber)
*
Subscriber Date of Birth
*
-
Month
-
Day
Year
Date
Insurance Company (Primary Insurance)
*
Insurance ID # (Primary Insurance)
*
Group # (Primary Insurance)
Policy Start Date (Primary Insurance)
Policy End Date (Primary Insurance)
Marital Status
Name of Spouse (If Applicable)
Age of Significant Other (If Applicable)
Briefly describe your relationship with current spouse/significant other (if applicable)
Emergency Contact or Parent Name
*
Emergency Contacts Relationship
*
Emergency Contact or Parent's Phone Number
*
Briefly state why you are seeking treatment at this time. (Important for Placement)
*
Services Requested (Check All That Apply)
*
Counseling/Therapy
Medication Management
Psychological Testing
Gifted Testing
If Counseling, Which Services? (Check All That Apply)
*
Individual Counseling
Couples Counseling*
Family Counseling*
If Couples or Family's Counseling is being requested, Please note that an intake form will need to be submitted for each individual.**
Please note any significant physical medical history and or non-psychiatric hospitalizations. (Required)
Please note any food or medication allergies.
Is the Patient pregnant, or post-partum by less than six weeks?
Yes
No
Does the patient have a history of drug/alcohol use?
Yes
No
If drug/alcohol use is current, please state the frequency of use.
Has treatment been received for drug/alcohol use?
Yes
No
Please detail when, by whom, and the nature of the treatment
Is there a history of physical or sexual abuse?
Is there a history of physical or sexual abuse? (Required)
Yes, Physical
Yes, Sexual
Yes, Both
No
At what point in time did this abuse occur?
Has outpatient mental health treatment/psychotherapy/counseling been completed previously?
Yes
No
Please detail when, by whom, and the nature of the treatment.
Has the patient experienced any psychiatric hospitalizations? (Required)
Yes
No
Please detail when, by whom, and the nature of the treatment.
Is the patient currently taking, or have ever taken, any psychiatric medications? (Required)
Yes
No
Please detail any psychiatric history.
Is there any history of suicidal thoughts, threats, or attempts? (Required)
Please list the dates and/or frequency of these events:
Pharmacy Name
Pharmacy Phone Number
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are the Parents deceased? If so, please state below which parent and how old.
Are the caregivers divorced?
Yes
No
During pregnancy, did the birth mother use drugs or alcohol?
Yes
No
During pregnancy or birth, were there any complications?
Yes
No
Please detail the complications:
Birthplace
How would you describe academic performance during childhood?
Excellent
Average
Poor
If poor, explain:
Highest Level of Education
Please Select
No Formal Schooling
Still in K-12
High School Diploma
GED
Some College
Associates Degree
Bachelors Degree
Masters Degree
Doctorates Degree
Professional
Technical Schooling
Currently a student?
Yes
No
If Yes, Where?
Employment Status?
Please Select
Full-Time
Part-Time
Military
Retired
Unemployed
Student
Other
Occupation? (If Applicable)
Who is the employer? (If Applicable)
Are you a member of law enforcement, a first responder, or military personnel?
Yes
No
Prefer not to respond
Is there a history of arrests?
Yes
No
Prefer not to respond
Submit
Should be Empty: