Nike Carli, LCSW-R ~Patient Information & History Form

Nike Carli, LCSW-R

5500 Main Street, Suite 259, Williamsville, New York 14221 Phone: 716-633-6900
Patient Information & History Form
Please provide the following as best you can. I appreciate your willingness to cooperate in helping me obtain your history and information.
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Name
  
  First NameLast Name
- Gender
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  
  Area CodePhone Number
- Birth Date
  
  MonthDayYear
- Marital Status
- Number of years married or cohabitating:
- Spouse/Companion’s Name
- Employment Status
- Employer's Name
- Employer's phone number
- Employer's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Emergency Contact Name:
- Relationship
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- How did you hear about me? (Who referred you?)
- Will you be utilizing insurance as a form of payment
- Primary Insurance:
- Is pre-authorization required?
- Certificate ID #
- Group #
- Subscriber Name
  
  First NameLast Name
- Effective Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Have you used your benefits this year with any other counseling service?
- Number of Visits
- Secondary Insurance
- Is pre-authorization required?
- Certificate ID #
- Group #
- Subscriber Name
  
  First NameLast Name
- Effective Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Have you used your benefits this year with any other counseling service?
- Number of Visits
- I authorize the release of any medical or other information necessary to process any insurance claim(s). I also authorize payment of medical benefits for services described on above mentioned claim(s). I understand that I am ultimately responsible for payment of all services rendered and that I will be charged for appointments if canceled with less than 24 hours notice. In order to utilize insurance, I understand that all copays must be paid at time of service.
- Signature
- Prior Mental Health History
- Have you ever seen a psychiatrist, therapist, or counselor?
- If so, please give names and dates:
- Was it helpful, not helpful, or harmful?
- Have you been or are you on medication? (tranquilizers, antidepressants, others)
- If so, give names of medications and dates that you have been on them and how you responded to them
- Family History
- Do any members of your family (grandparents, uncles, etc.) see a mental health professional?
- Is there alcoholism in your family?
- Have any members of your family ever committed suicide?
- If yes to any of the above please describe the relationship.
- Do you have any children?
- Name and age of children
- Do you have any brothers or sisters?
- Name and age of siblings
- Social History
- Education
  Highest grade completed
- Are you currently employed?
- Are you having problems related to your present job, with others workers or supervisors?
- If yes, please describe the problem
- Military History
- Have you been in the Military?
- If yes, give branch of service, dates, rank on discharge, disciplinary action, and any disability.
- Legal History
- Have you ever been arrested?
- Do you have any legal problems?
- If yes to either of the above please describe
- Medical History:
- Are you on medication for a medical condition (ex: insulin, heart pills, seizure medication)?
- Names and dosages of all current medications:
- Have you had any surgeries?
- If yes, give approximate year and name of procedure ( ex: appendix, tonsils, open heart, etc.)
- List all medical conditions (ex: allergies, diabetes, heart disease, high blood pressure, etc.)
- Have you ever had any of the following symptoms or difficulties?
- Other
- Summery
- What do you expect from your treatment? What are your goals?
- Is there any other information which might help to better understand your problems?
- What brings you joy or helps you deal with current stressors?
- I have received a copy of the Patient Bill of Rights and Treatment Information, and have been given an opportunity to review it.
- I have received a copy of the Notice of Privacy Practices, and have been given an opportunity to review it.
- Should be Empty: