APRN Intake Form

APRN Intake Form

Welcome!
Name*

First NameLast Name
Email*
example@example.com
Phone*
Date of Birth*

MonthDayYear
Date
Preferred Method of Contact*

E-mailHome PhoneCell Phone
I am looking for....*

Initial Evaluation for MedicationHelp with my current medicationTo transition off of medicationNatural alternatives to medicationTherapyClarity of diagnosisOther
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 personOnlineI'm flexible
Do you have any history of the following...*

Mold exposureLead, mercury, or other heavy metalsEnvironmentally toxic work environmentsContaminated drinking waterHigh levels of pesticidesFrequent use of artificial scents such as air fresheners, colognes, or scented candlesMetal dental fillingsNone of the above
Please list any surgeries or hospitalizations (including c-sections is applicable):
How did you hear about us?*

I am a returning clientWord of mouthGoogleA family member or friendSchool systemSocial mediaPsychology TodayMy insurance companyMy providerOther
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 NameLast Name
Policy Holder Date of Birth*

MonthDayYear
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:*

PANDASSIBOCeliac DiseaseADD/ADHDAutismHypothyroidismTraumatic Brain InjuryConcussionPTSDStrokeEating DisorderBipolar DisorderNutritional DeficitsSleep ApneaIBS/Leaky GutSensory Integration DisorderPeri-Menopause/MenopauseMigrainesSchizophrenia/Schizo-affective DisorderNone
Please list your current mental health symptoms:*

AnxietyDepressionVisual/Auditory HallucinationsIrritabilityLow MotivationDifficulty ConcentratingIntrusive thoughtsLonelinessGriefMood SwingsSuicide IdeationSubstance UseIrregular periodsOtherNone
Do you use tobacco?*

NoDailyWeeklyLessFormer User
Do you use alcohol?*

NoDailyWeeklyLessFormer User
Caffeine use?*

NoDailyWeeklyLessFormer User
Are you currently taking prescription medication?*

YesNo
Prescribing Doctor's Name

First NameLast Name
Prescribing Doctor's Phone
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?*

YesNo
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
Should be Empty:

APRN Intake Form

Insurance Information

Medical History

Mental Health History