Patient Information
Guardian/Guarantor Information
Emergency Contact
Insurance Policy Information
Primary Care Doctor/Provider Permission to contact for continuity of care?
Personal & Medical History
Please describe what problem(s) or challenges you are seeking help for.
Current symptoms (check all that apply)
Have youever felt that you did not want to live or had thoughts of suicide/self harm?
List all prescription and over-the-counter medications, vitamins, and supplements you are currently taking, how often, and for how long:
Physical illnesses/symptoms (check all that apply)
Past Psychiatric History: Have you previously received outpatient mental health treatment?
If Yes, please describe where, when, and for what problems:
Have you previously received inpatient mental health treatment (ex. psychiatric hospitalization)?
If Yes, please describe where, when, and for what problems:
List all psychiatric medications you have previously taken, how often, for how long, and how helpful or unhelpful it was: (ex. sedatives, antipsychotics, mood stabilizers, antidepressants, antianxiety, ADD/ADHD medications)
Has anyone in your family been diagnosed with or treated for (check all that apply):
Are you seeking services for a disability application or legal/litigation reasons? Anything else you would like us to know?
By electronically signing this form, you agree your electronic signature is the equivalent of your manual/handwritten signature on this form. You also agree that the electronic signature appearing on this form is the same as handwritten signatures for the purposes of validity and consent.
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