APRN Intake Form
Welcome!
Name
*
First Name
Last Name
Email
*
example@example.com
Phone
*
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Method of Contact
*
E-mail
Home Phone
Cell Phone
I am looking for....
*
Initial Evaluation for Medication
Help with my current medication
To transition off of medication
Natural alternatives to medication
Therapy
Clarity of diagnosis
Other
Please list all, if any, current medications you are taking and the dosages. Please include any supplements you take regularly. If you do not currently take any medications, please write "none."*
*
Do you have any allergies? If yes, please list:
I prefer to meet
*
In person
Online
I'm flexible
Do you have any history of the following...
*
Mold exposure
Lead, mercury, or other heavy metals
Environmentally toxic work environments
Contaminated drinking water
High levels of pesticides
Frequent use of artificial scents such as air fresheners, colognes, or scented candles
Metal dental fillings
None of the above
Please list any surgeries or hospitalizations (including c-sections is applicable):
How did you hear about us?
*
I am a returning client
Word of mouth
Google
A family member or friend
School system
Social media
Psychology Today
My insurance company
My provider
Other
If you were referred by your PCP, what is their name?
Insurance Information
Name of Insurance (if None write N/A)
*
Name of Policy Holder
*
First Name
Last Name
Policy Holder Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Patient
*
Member ID
*
Group Number
*
Rx/Group Number (If none, write N/A)
*
BIN Number (If none, write N/A)
*
Preferred Pharmacy (Name/Address/Phone)
Medical History
Have you ever been evaluated for or diagnosed with any of the following:
*
PANDAS
SIBO
Celiac Disease
ADD/ADHD
Autism
Hypothyroidism
Traumatic Brain Injury
Concussion
PTSD
Stroke
Eating Disorder
Bipolar Disorder
Nutritional Deficits
Sleep Apnea
IBS/Leaky Gut
Sensory Integration Disorder
Peri-Menopause/Menopause
Migraines
Schizophrenia/Schizo-affective Disorder
None
Please list your current mental health symptoms:
*
Anxiety
Depression
Visual/Auditory Hallucinations
Irritability
Low Motivation
Difficulty Concentrating
Intrusive thoughts
Loneliness
Grief
Mood Swings
Suicide Ideation
Substance Use
Irregular periods
Other
None
Do you use tobacco?
*
No
Daily
Weekly
Less
Former User
Do you use alcohol?
*
No
Daily
Weekly
Less
Former User
Caffeine use?
*
No
Daily
Weekly
Less
Former User
Are you currently taking prescription medication?
*
Yes
No
Prescribing Doctor's Name
First Name
Last Name
Prescribing Doctor's Phone
Format: (000) 000-0000.
Mental Health History
Why you are seeking treatment?
*
Days/times you are available
*
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
*
Yes
No
Are you a veteran or an active member of the military?*
*
Do you have a history within the last 6 months of suicide attempt?
*
Are you currently involved in any legal disputes?
*
Are you currently in a household that is experiencing domestic violence?
*
*Domestic Violence is a condition that requires special care and expertise. Please let our Intake Specialist know if your are currently in a situation where you are experiening DV or if you are at risk of DV so they can do their best to help you find the right services.
If you are seeking services for your child, please describe the marital and custody status of the child's parents. Is DCF involved?:*
*
Tell us a little about you, and your situation to help us match you with the right person:
*
Additional comments or concerns
Submit
Should be Empty: