Anew Psychiatry Patient Treatment Intake
Please fill out all information to the best of your ability.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Method of Contact:
Phone
Email
Text
Gender
*
Please Select
Male
Female
Other
Prefer not to answer
Pronouns
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of treatment interested in:
*
Insurance Information
Insurance Company:
*
Subscriber Name:
*
Subscriber DOB:
*
-
Month
-
Day
Year
Date
Member ID #:
*
Group #:
*
I understand
*
I am responsible for verifying my insurance benefits and for all charges not covered by insurance.
Psychiatric History
Reason for seeking services (check all that apply):
*
Depression
Anxiety
ADHD
Bipolar Disorder
PTSD
Panic Attacks
Sleep Issues
Mood Swings
Trauma
Medication Management
Other
Briefly describe your current concerns:
*
Previous mental health treatment?
*
Yes
No
If yes, please explain (provider, dates, type of treatment):
Past psychiatric hospitalizations?
*
Yes
No
If yes, please explain:
Have you ever had thoughts of harming yourself?
*
Have you ever had thoughts of harming others?
*
History of suicide attempts?
*
Have you tried any of the following integrative psychiatric treatments?
*
TMS
ECT
Psychedelics
Ketamine/ Esketamine
Vagal Nerve Stimulator
None
Other
MEDICATION HISTORY
Please list ALL CURRENT medications you are taking:
*
Psychiatric medications currently on or have tried in the past:
*
Please list any natural remedies and vitamins, you are currently taking:
Medical History
This questionnaire is an essential part of providing you with the best possible healthcare. Your answers will help us understand any problems you may have. Please answer every question to the best of your ability.
Who is your Current Primary Care Physician?
Do you see any specialty doctors? (cardiologists/neurologists/etc.) List names and location:
Do you have any allergies (including medications)?
*
Yes
No
If yes, please list.
Have you ever had any serious illness?
*
Have you ever undergone surgery?
*
Please select all of the following that apply to you
*
Have you ever been hospitalized for a medical reason?
*
Substance Use
Do you currently or have you ever used any of the following?
*
Rows
Never
Occasionally
Frequently
In the past
Alcohol
Cannabis
Opioids
Benzodiazepines (e.g., Xanax):
Cocaine/methamphetamines:
Hallucinogens (e.g., LSD, psilocybin):
Ketamine (outside medical use):
Cigarettes, vapes, tobacco use
Caffeinated Beverages (more than 2)
Coffee (more than 6 cups a day)
If other or any comments...
Social History
Marital Status
Highest degree obtained:
Do you have any children?
Yes
No
If so, how many and how old?
Do you currently work or attend school?
Yes
No
What is your current occupation, or what are you in school for?
Do you use any assistive devices or have mobility issues?
Yes
No
Who is in your support system?
Do you exercise regularly?
Yes
No
If yes, how often?
Hobbies and Interests:
Rate your current level of functioning (1 = very poor, 10 = excellent): ___ /10
How many of hours do you sleep per night on average?
How would you describe your usual sleeping habits?
Family History
Does anyone in your family suffer from any psychiatric disorder(s)?
Rows
Mother
Father
Sibling
Children
Mat. Grandparent
Pat. Grandparent
Bipolar Disorder
Manic Depression
Anxiety Disorder
ADHD
Substance Abuse
Schizophrenia
Other
Comments
Save
Submit
Should be Empty: