Intake Form

Patient Information

Last Name

First Name

M.I.

Date of Birth

Address

Phone

Emergency Contact (Name, Phone, Relationship)

Who Referred You To Us?

Medical History

Current Medications

Name & Dosage

Start & Stop Dates

Side Effects

Effective?

Why Prescribed?

Name & Dosage

Start & Stop Dates

Side Effects

Effective?

Why Prescribed?

Name & Dosage

Start & Stop Dates

Side Effects

Effective?

Why Prescribed?

Past Medications

Name & Dosage

Start & Stop Dates

Side Effects

Effective?

Why Prescribed?

Name & Dosage

Start & Stop Dates

Side Effects

Effective?

Why Prescribed?

Name & Dosage

Start & Stop Dates

Side Effects

Effective?

Why Prescribed?

Do you have any allergies to medications?

Any metal implanted in your head or neck?

Do you currently drink alcohol?

Do you use illicit substances?

Are you presently in therapy?

Are you presently under the care of a psychiatrist?

Have you ever been placed on a psychiatric hold?

Current psychiatric concerns?

Past psychiatric concerns?

Do you self-harm?

Have you ever self-harmed?

Do you currently experience suicidal ideation?

Do you currently experience homicidal ideation?

In the past, have you attempted suicide?

Even if no treatment has fully resolved your symptoms, which treatment has been the most effective in relieving your symptoms?

Personal History

What is your current living situation?

Occupation / Employer

Social History

Do you use tobacco?

What is your caffeine intake?

Family History

Family history of psychiatric conditions

Family history of substance use / abuse

Insurance Information

Primary Subscriber

Insurance Company

Insurance Phone

Group Number

Select Your Plan

Upload Your Insurance Card - Front & Back

Insurance Card Front

Insurance Card Back

Emergency Contact

Name

Phone

Relationship

Consent

Acceptance

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Patient Intake Form