Relax Your Mind Services NEW PATIENT REGISTRATION

Note: If you have been a patient here before, please fill in only the information that has changed.

Today's Date: Legal Name: Preferred Name:
Todays Date*

MonthDayYear
Date
Legal Name*
Preferred Name*
Age*
Sex*
Male, Female, or Trans*
Preferred pronouns*
Please upload Primary and Secondary Insurance Card (Front of card)*

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Please upload Primary and Secondary Insurance Card (back of card)*

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Please upload Driver's License (Front and back of card)*

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Please upload Driver's License (Back of card)*

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Please upload Credit Card (Front of card)*

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Please upload Credit Card (Back of card)*

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Sexual Orientation:*

LesbianGayBisexualStraightQueerNot sureOther
Race / Ethnicity*

African American/BlackAsianCaucasian/WhiteMultiNative American/Alaskan NativeInuit/ Pacific IslanderHispanic/Latino/LatinaNot Hispanic/Latino/LatinaOther
Straight Queer Not sure
Address*
Social Security
City State Zip*
Date of Birth*

MonthDayYear
Date
Home Phone*
May I Call This Number? *
Leave a Message? *
Cell Phone*
May I Call This Number? *
Leave a Message? *
Email*
example@example.com
May I E-Mail Reminders? : *
Calls or email will be discreet but please indicate any restrictions*
example@example.com
Person Responsible for Bill*
Relationship*
Phone*
Employer*
Address*
Address*

Occupation:
Work Phone*
May I Call This Number? *
Leave a Message? *
Primary Insurance Company Name*
Name of Insured*
Policy Member Number*
Group Member Number*
Copay*
Subscriber Name ID*
Phone Number*
Address*
Relationship*
frontdesk@relaxyourmindservices.com
RELAX YOUR MIND SERVICES
Secondary Insurance Company
Name of Insured
Subscriber Name ID
Policy Member Number
Group Member Number
Copay
Relationship
MEDICAL & REFERRAL INFORMATION
Name of Physician / Primary Care Provider*
Phone*
Name of Therapist / Counselor*
Phone*
Were you referred?: *
Relationship*
May I have your permission to thank this person for the referral?: *
Household Status:
Relationship Status: *
Living Environment: *
If some kind of emergency arises and we cannot reach you directly, or we need to reach someone close to you, whom should we call? Contact:
Relationship*
Address*
Home Phone
Cell Phone*
Work Phone
Legal Next of Kin*
Relationship*
Address*
Home Phone
Cell Phone*
Work Phone
frontdesk@relaxyourmindservices.com
Any changes in your general physical health in the past 3-6 months? Please type below: If No, type "no". If Yes, please indicate condition.*
Do you experience chronic pain? Please type below: If No, type "no". If Yes, please indicate condition, how managed (PT, Rx, etc)? *
MEDICAL HISTORY - Please type below: If No, type "no". If Yes, please indicate condition.*
Operations and/or Hospitalizations: (Please list surgeries and/or hospitalization reasons and dates) *
Please Type: 1. Clinic Name, 2. Primary Care Provider (PCP) Name 3.Telephone number 4. Fax number*
FAMILY MEDICAL HISTORY - If yes, who? (Parent, sibling, children, aunt/uncle, grandparent) Please type below:If No, type "no". If Yes, please indicate relation, condition, treatments, & medications.*
FAMILY MENTAL HEALTH HISTORY: Has anyone in your family ever been diagnosed with a mental illness, had a psychiatric hospitalization or suicide attempt, or struggled with drugs or alcohol? If No, type "no". If Yes, please indicate relation, condition, treatments, & medications.*
RELAX YOUR MIND SERVICES
CURRENT MEDICATIONS Please list your current medications, vitamins, & herbal supplements*
MEDICATION ALLERGIES/REACTIONS
Medication Allergies/Reactions*
Medication Allergies *
Other Allergies (Food/Environment)*
Food/Environment Allergies *
PREVENTION
Fire Arms Kept in Home*
Tobacco Current packs a day*
Type*
Alcoholic Drinks a week*
Caffeine: ________ caffeinated beverages a day*
Sexual Partners: ________ last 12 months*
Activity*
Do you have an advanced health directive, such as a "do not resuscitate"?*
Does someone have power of attorney, or guardianship giving them the power to make decisions about your care in life-threatening situations, or a psychiatric advance directive?*
Name relationship*
I I verify that the above information is accurate to the best of my knowledge. I understand that providing in- correct information can be dangerous to my health. It is my responsibility to inform my provider of any changes in my medical status.

Patient/Parent/Guardian signature Prescriber signature
PatientParentGuardian signature*

Clear
Date*

MonthDayYear
Date
frontdesk@relaxyourmindservices.com
Should be Empty:

RELAX YOUR MIND SERVICES

RELAX YOUR MIND SERVICES

MEDICATION ALLERGIES/REACTIONS

PREVENTION