AFP New Patient Intake Form

New Patient Information

For any inquiries, please call (503) 922-1999 (Oregon) or (757) 239-2293 (Virginia Beach or email us at alisfamilypsychteam@hushmail.com

Please ensure all sections of the intake form are filled out thoroughly and accurately.
Alis Family Psychiatry*

OregonVirginia Beach
Patient First Name*
Patient Last Name*
Preferred Name
Date of Birth (mm/dd/yyyy)*

MonthDayYear
Date
Gender at birth*

MaleFemale
Gender identity:
e.g., woman, man, nonbinary, trans, agender, etc.
Sexual orientation*

Heterosexual (straight)LesbianGayBisexualPansexualAsexualQueerQuestioningPrefer not to sayOther
What pronouns do you use?*
e.g., she/her, he/him, they/them, etc.
Patient’s Social Security Number*
Insurance Guarantor’s Social Security Number*
If same as patient, please re-enter
Preferred pharmacy*
Address and zip code
Marital Status*

SingleMarriedDivorcedWidowedOther
Highest level of education:

Graduated high school or equivalentCollege undergraduateAssociate degreeBachelor’s degreePost-graduate degreeOthers,pleasespecify
Occupation
Hours worked per week
Permanent Address
House/Apt/Bldg*
Street*
City*
State*
Zip Code*
Contact Information
Email address*
example@example.com
Home Phone*
Cell Phone*
Preferred mode of communication*

CallSMSEmailPatient portal
INSURANCE
Insurance Name*
e.g., “Blue Cross Blue Shield, Aetna, etc.”
Member/Subscriber ID:*
Group number
Insurance Plan Type (HMO/PPO/POS/NA)
Policy Holder Name:*
Policy Holder Date of Birth

MonthDayYear
Date
Primary Policy Holder Name*
Effective Date of Plan

MonthDayYear
Date
Specialist Copay Amount
Relationship of patient to policyholder:
IF ANOTHER PERSON IS RESPONSIBLE FOR CHARGES:
Name
Relationship
Address
Contact number
EMERGENCY CONTACT INFORMATION:
Policy holder DOB:*
Name*
Relationship*
Address*
ContactNumber*
Medical History
Primary Care Provider
Provider name/Clinic:*
Address
Phone Number
Fax Number
Past Medical History*
If none, please indicate “None.”
Past Surgical History*
If none, please indicate “None.”
Vitals
Weight*
Please indicate in lbs or kg.
Height*
Please indicate in feet/inches or cm
Most Recent Blood Pressure*
e.g., 120/80 mmHg
Heart Rate*
e.g., 72 bpm
Current Medications

(include nutritional supplements, herbal supplements and over-the-counter medications)
Name of Medication*
If none, please indicate “None.”
Dose
Frequency
Approximate Start Date
Are you under Medication-assisted treatment (MAT) with suboxone or methadone?*

YesNo
General allergy list & side effect (food & and others):*
If none, please indicate “None.”
Drug allergy list and side effect *
If none, please indicate “None.”
Known Failed Medications and side effect (and reason if known):*
If none, please indicate “None”.
Drug and Alcohol History
Alcohol

YesNo
THC/Cannabis

YesNo
Opioids

YesNo
Cigarettes or other tobacco products:

YesNo
Caffeine intake:

YesNoOther
Others: (specify/explain)
Have You Ever Had: Please review and check all that apply.

SeizuresFracture or Severe InjuryChest PainsFainting SpellsShortness of BreathHeart PalpitationsEating DisordersNone of the followingOther
Psychiatric History (Please list all psychiatric history you have been diagnosed and/or treated for)*
If none, please indicate above.
Family Psychiatric History (Please list known psychiatric conditions your family members have beendiagnosed with and/or treated for.)*
If none, please indicate above.
History of Abuse (any physical, sexual, emotional, etc.)
If none, please indicate above.
Former/Current Psychiatrist and Therapist: (Please list name, address and phone number)
If none, please indicate above.
How did you hear about Alis Family Psychiatry?
(PsychToday, ZocDoc etc.)
What is the reason for your visit today?
Chief complaint
Other notes for your visit
Insurance card (front)*

Cancelof
Insurance card (back)*

Cancelof
Signature

Clear
Patient Attestation and Consent

I attest that the information I have provided on this intake form, including all medications, dosages, and related medical details, is true, complete, and accurate to the best of my knowledge. I understand that providing false, incomplete, or misleading information may impact my treatment and care. I further acknowledge my responsibility to promptly notify my healthcare provider of any changes to my current medications or medical history.
Yes, I confirm this attestation
Consent to Communication (Mandatory)

By selecting “Yes,” I consent to receive text messages, phone calls, and voicemail messages from Alis Family Psychiatry at the contact information I have provided, for purposes related to my treatment, scheduling, billing, and other healthcare operations. I understand that standard message and data rates may apply.
Yes, I consent to receive text and voice messages at the contact information provided.
This message and any documents attached to it are confidential and may contain information that is protected from disclosure by various federal and state laws, including the HIPAA privacy rule (45 C.F.R, Part 164) This information is intended to be used solely by the entity or individual to whom this message is addressed. If you are not the intended recipient, be advised that any use, dissemination, forwarding, printing, or copying of this message without the sender's written permission is strictly prohibited and may be unlawful. Accordingly, if you have received this message in error, please notify the sender immediately by return e-mail or call (503 922-1999), and then delete this message.
Name of Medication, Dose, Frequency & Approximate Start Date*
If none, please indicate “None.”
Name of Medication, Dose, Frequency & Approximate Start Date
Should be Empty:

Permanent Address

Contact Information

INSURANCE

IF ANOTHER PERSON IS RESPONSIBLE FOR CHARGES:

EMERGENCY CONTACT INFORMATION:

Medical History

Primary Care Provider

Vitals

Current Medications

Drug and Alcohol History

Patient Attestation and Consent

Consent to Communication (Mandatory)