Name:, Sex:, Age: Ethnicity, Race. Date of Birth:, address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( )
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1 Adult Patient Information Name:, Sex:, Age: Ethnicity, Race Date of Birth:, address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( ) Cell: ( ) Referral by: Person to notify in case of emergency: Emergency Contact Telephone Number: ( ) School/ Employer: Marital Status: Insurance Company Information Name of Insurer: Member Number: Authorization Number: Insurer s Telephone Number: ( ) ; ( ) Insurer s [1]
2 Coordination of Care: Primary Care Doctor ; Phone number ; Telephone number Street ; City ; State Zip Therapist/Psychologist ; Phone number ; Telephone number Street ; City ; State Zip I agree to release my diagnosis and treatment recommendation information to my insurance company for billing and coordination of care: yes no I agree to release my diagnosis and treatment recommendation information to my primary care provider for coordination of care: yes no I agree to release diagnosis and treatment recommendation information to my therapist/psychologist for coordination of care: yes, no I would like help with the following problem/ symptoms. My Psychiatric Diagnoses are: [2]
3 Medical History Please indicate if you suffer from any of the following conditions, circle current, past or both and circle a number, 1 through 5 to indicate severity. 1 is mild, 3 is moderate, 5 is severe. Infectious diseases Current / Past Allergies Current / Past Asthma/lung disease Current / Past Diabetes Current / Past Thyroid disease Current / Past Myocardial infarction Current / Past Hypertension Current / Past Liver disease Current / Past Cancer Current / Past Stroke Current / Past Head injury Current / Past Seizures Current / Past Suffocation/ drowning Current / Past Loss of consciousness Current / Past Headaches Current / Past Memory loss Current / Past Neurological disorder Current / Past Easy Bleeding/bruising Current / Past Sexual dysfunction Current / Past Pregnancy Current / Past Menopause Current / Past Kidney disease Current / Past Chronic pain Current / Past Excessive menstrual bleeding or Current / Past pain Gynecological condition/procedure Current / Past Skin Condition Current / Past Surgical Procedures Current / Past Medication Allergies: Please list all medications you are currently taking for medical illness: [3]
4 Family Psychiatric History Please indicate the blood relationship of your family members with a psychiatric condition as follows: 1 st degree relative biological child or parent; 2 nd degree- biological grandparent, cousin, uncle, aunt, niece, nephew Psychiatric care Maternal / Paternal 1 st degree/ 2 nd degree Anxiety disorder Maternal / Paternal 1 st degree/ 2 nd degree Depressive disorder Maternal / Paternal 1 st degree/ 2 nd degree Manic depression or Maternal / Paternal 1 st degree/ 2 nd degree Bipolar disorder Schizophrenia Maternal / Paternal 1 st degree/ 2 nd degree Psychotic disorder Maternal / Paternal 1 st degree/ 2 nd degree Attention deficit/ Maternal / Paternal 1 st degree/ 2 nd degree hyperactivity disorder Learning disorders Maternal / Paternal 1 st degree/ 2 nd degree Mental retardation Maternal / Paternal 1 st degree/ 2 nd degree Autistic disorder Maternal / Paternal 1 st degree/ 2 nd degree Substance abuse Maternal / Paternal 1 st degree/ 2 nd degree Psychiatric Maternal / Paternal 1 st degree/ 2 nd degree hospitalization Eating Disorder Maternal / Paternal 1 st degree/ 2 nd degree Narcolepsy Maternal / Paternal 1 st degree/ 2 nd degree Sleep disturbance Maternal / Paternal 1 st degree/ 2 nd degree Homicide attempt Maternal / Paternal 1 st degree/ 2 nd degree Suicide attempt Maternal / Paternal 1 st degree/ 2 nd degree Social History of Client: Highest degree of education obtained: With whom do you live? [4]
5 Type of employment: Sexual Orientation: Number of Children: Legal problems/ circumstances: Main source of stress: Negative experiences physical or sexual abuse, domestic violence, trauma, loss: Personal strengths/ weaknesses: Personal goals/aspirations/ hopes/ dreams: Spiritual/religious orientation/cultural issues [5]
6 Psychiatric History of Client Please indicate any psychiatric/ psychological care you have received, your approximate age at that time and your satisfaction with the treatment: List all psychiatric medications prescribed; the reason prescribed; the duration; and effect by completing the following table. Name of medication Reason prescribed Date started Date ended/ reason for stopping Helpful? Yes/No Side effects? [6]
7 Psychiatric History Continued: Please indicate if the following is current, past or both. Please indicate the frequency using the following scale: Almost Never (1); Sometimes (3); Almost Always (5) Depression Symptoms When Frequency Depressed mood Current / Past Loss of pleasure Current / Past Loneliness Current / Past Decreased appetite Current / Past Increased appetite Current / Past Poor concentration Current / Past Crying spells Current / Past Suicide thoughts Current / Past Homicide thoughts Current / Past Isolation Current / Past Irritability Current / Past Weight loss Current / Past Weight gain Current / Past Anger Current / Past Mania Symptoms When Frequency Increased energy Current / Past Racing thoughts Current / Past Rapid speech Current / Past Less than four hours Current / Past sleep per night Euphoria Current / Past Invincibility Current / Past Irritability Current / Past Anger Current / Past Violent outburst Current / Past Sexual impulsivity Current / Past Financial impulsivity Current / Past Mood swings Current / Past [7]
8 Anxiety Symptoms When Frequency Excessive worrying Current / Past Muscle stiffness Current / Past Panic attacks Current / Past Avoiding things Current / Past Unwanted fears Current / Past Unwanted rituals Current / Past Unwanted habits Current / Past Procrastination Current / Past Psychosis Symptoms When Frequency Hearing voices Current / Past Seeing things Current / Past Paranoia Current / Past Special powers Current / Past TV, Radio, News talks to you or about you personally Current / Past ADHD Symptoms When Frequency Overly active Current / Past Constantly in motion Current / Past Constantly talking Current / Past Constantly interrupting Current / Past Annoying to peers Current / Past Annoying to adults Current / Past Constantly distracted Current / Past Forgetful Current / Past Inattentive Current / Past [8]
Preferred Name (s): Local Address: City: State: Zip: Permanent Address: City: State: Zip: Years of Education: Occupation: Gender: M F
Today Date: Client Name(s) : Psychological Consultants Northgate Center 1210 ½ -7 th Street NW, Suite 216 Rochester, MN 55901 www.psychologicalconsultants1.com Office: (507) 252-9292 Fax: (507) 252-9203
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone: Private email address: Student? If yes, where and major? May we leave
MERLE MULLINS COUNSELING REGISTRATION FORM (Please Print) CLIENT INFORMATION
MERLE MULLINS COUNSELING REGISTRATION FORM (Please Print) CLIENT INFORMATION Last Name: First: Middle:! Mr.! Mrs. Today s date: / /! Miss! Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid
MINDFUL WELLNESS CENTER, PLLC
PATIENT HISTORY NAME DATE PLEASE TAKE YOUR TIME AND COMPLETE THE ENTIRE FORM. You may use the back if needed for more explanation. Identifying Information: Date of Birth: Age: Sex: Place of Birth: Religion:
Client Intake Form. First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip:
Client Intake Form First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip: Tel: Home: Okay to leave message? (Circle one) Yes No Tel: Work: Ext Okay to leave message? (Circle one)
PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT
DOB: / / / PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT Date Age Gender M F Current address: Married. Single Separated Divorced Widowed If patient is a child, he/she
Child/ Adolescent Questionnaire
Oconee Center for Behavioral Health 1360 Caduceus Way Building 400, Suite 102 Tel 706-286-8442 Fax 706-310-6907 Child/ Adolescent Questionnaire Patient s Name: Date of Birth: / / Patient s Birthplace:
Address: Spouse/Partner Name: Phone: Address:
Adult Wellness Assessment Please take a few minutes to fill out this form. The information will be helpful in better understanding your individual needs and situation. Thank you. Personal Information Name:
Health and Social Information 1. How is your physical health at present? (Please circle) Poor Unsatisfactory Satisfactory Good Very good
Client Health History and Background Please provide the following information for my records. Continue on the backside of this form if you need additional space. General Information Name: Date: Birth Date:
Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -.
New Client Intake Date: Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -. Employer Email: Emergency Contact Name Relationship Phone number TREATMENT
Client s Name: Street City State Zip. Home Phone Work Phone Cell Phone. Student: Full-time Part-time Grade School. Current or past Education:
Office of: Sarah Horvath, LCSW Self-Report Form Page 1 Client s Name: Person completing report: Relation to Client: Street City State Zip Home Phone Work Phone Cell Phone Email: Date of Birth: Age: Gender:
HERTFORDSHIRE PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST. Referral Criteria for Specialist Tier 3 CAMHS
Referral Criteria for Specialist Tier 3 CAMHS Specialist CAMHS provides mental health support, advice and guidance and treatment for Children and Young People with moderate or severe mental health difficulties,
CLIENT INFORMATION FORM. Name: Date: Address: Gender: City: State: Zip: Date of Birth: Social Security Number:
Name: Address: Gender: City: State: Zip: Date of Birth: Social Security Number: Contact Telephone Numbers Please complete relevant information and indicate the number at which you wish to be contacted
Client: Date of Birth: Date of Report: MENTAL STATUS EXAMINATION REPORT 1. Identifying Information
Client: Date of Birth: MENTAL STATUS EXAMINATION REPORT 1. Identifying Information Date of Report: 2. Reason for Assessment (Please indicate referral source, precipitating circumstances and chief complaints)
Adult Information Form
1 Client Name: Age: DOB: Today s Date Address: City: State: Zip: Home Phone: ( ) Ok to leave message? YES NO Work Phone: ( ) Ok to leave message? YES NO Current Employer (or school if a student): Gender:
Anxiety Depression Sleep problems Thoughts of suicide. Panic Unusual thoughts Anger outbursts Changes in weight
Client Information Name: Biographical Information Please complete this form, which will provide information useful in treatment. If you are not the patient (for example, if you are giving information about
Adult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
DR. CESTNICK ADULT BACKGROUND QUESTIONNAIRE. Birth date: Age: Sex (circle one): Male Female. Home address: City: Zip Code:
DR. CESTNICK ADULT BACKGROUND QUESTIONNAIRE Your name: Today s date: Birth date: Age: Sex (circle one): Male Female Home address: City: Zip Code: Phone: Home # Cell # Other # Email: School (if student):
Richard Senysyzn, MD Psychiatry for Adults 1260 River Acres Drive New Braunfels, TX , Fax. (888)
ADHD Evaluation Intake Form Patient Contact Information Patient Name: Date of Birth: Age: Last First MI Address: Email address: Contact phone number: Emergency Contact/Number/Relationship: Pharmacy: Primary
JILL L. KOFENDER, PHD, PLLC. Licensed Clinical Psychologist ADULT CLIENT QUESTIONNAIRE. Client s Name Today s Date Gender Age Birthdate
JILL L. KOFENDER, PHD, PLLC Licensed Clinical Psychologist ADULT CLIENT QUESTIONNAIRE Client s Name Today s Date Gender Age Birthdate Cell Phone Is it ok to text? Y N Is it ok to receive appt. reminders?
Elana Klemm, LPC, NCC Compassionate Care Counseling 4343 Shallowford Rd. Suite H-1B Marietta, GA ( ) NEW CLIENT INFORMATION
Elana Klemm, LPC, NCC Compassionate Care Counseling 4343 Shallowford Rd. Suite H-1B Marietta, GA. 30062 (404 783-7086) NEW CLIENT INFORMATION Last Name of Client First Name Middle Initial Social Security
Medication Allergies and Reactions: Please do not leave blank, write none if no allergies.
Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in providing you the best possible care. Today
Demographic Information Form
Demographic Information Form PATIENT INFORMATION Male Female Other / / (Patient Legal Last Name) (Patient Legal First Name) (MI) (DOB) Mailing: SSN#: - - Home Cell Relationship Status (circle one): Single
Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005
Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005 INTAKE FORM Name: Date: Gender: Female Male Date of birth: Address: Home phone: Cell: Okay to leave a message? Yes No Email: Emergency
Demographic Information Form
PATIENT INFORMATION Demographic Information Form / / Mailing: Male Female SSN#: - - Home Cell Relationship Status (circle one): Single / Married / Divorced / Widowed / Other: ( ) - ( ) - (Preferred Phone
PHARMACY INFORMATION:
Patient Name: Date of Birth: Referred by: Reason for Visit: Current psychiatric medications and doses: PHARMACY INFORMATION: Name of Pharmacy: Phone Number: Fax Number: Address: PRIMARY CARE PHYSICIAN
Life, Family and Relationship Questionnaire
Date of Initial Session: Client Name Date of Birth Address City Zip Phone Number Email Emergency Contact Relationship Emergency Contact Ph. # Client Name: Date: Life, Family and Relationship Questionnaire
COUNSELING ASSESSMENT REFERRAL AND BACKGROUND INFORMATION (Adult Form) cell telephones/fax #s/ addresses: (Spouse): (Emergency Contact):
Joanna C. Ioannides, LCSW *Lowry Counseling, LLC *7581 E. Academy Blvd. Ste 209 * Denver, CO 80230*Ph. (720)319-7319 Fax (303)379-4607* counseldenver@aol.com* COUNSELING ASSESSMENT REFERRAL AND BACKGROUND
ADULT History Form (To be filled out by the person seeking treatment)
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Evergreen Behavioral Health Psychiatric Intake Form. Name: Date: Date of Birth:!
Name: Date: Date of Birth: NOTE: Please also fill out the standard Evergreen Behavioral Health Adult Client Information form to accompany this one if you have not yet done so. Please also bring in recent
Client Name: Age: DOB: Date: What brings you to therapy?: How long has the problem been present?
Hope in Healing Counseling and Wellness, LLC Stacy Nunne, MA, LMFT, SEP, RN 600 West 78th Street, Suites 10A-C Mailing Address: PO Box 892 Chanhassen, MN 55317 Chanhassen, MN 55317 Phone: 952-215-5208
Do not write below this line DSM IV Code: Primary Secondary. Clinical Information
New Client Registration Today s date Name Age Sex Address Social security # Date of birth Home phone May I call you at this number? y / n Leave a message? y / n Other numbers at which I can call you Can
History Form for Adult Client
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Intake Form. Presenting Problems and Concerns. When did it start and how does it affect you:
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Joseph S. Weiner, MD, PC Patient History Form
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Child s name: Nickname: Date of Birth: / / Sex: Male Female SSN: Today s date: / / Parent s Name #1: Home phone: ( ) Cell: ( )
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CLIENT QUESTIONNAIRE Full Legal Name: DOB: / / Preferred Name: Email: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Can we leave voice messages for you at these numbers? Yes Text Messages?
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Conscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND (701)
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Name: Birthdate: Gender: Address: Phone: (Home) (Work) (Cell) Highest Education Attended: Occupation: Place of Employment:
CLIENT CLIENT INTAKE FORM Client Information Name: Birthdate: Gender: Address: Is it safe to send correspondence to this address, if needed? Yes No Phone: (Home) (Work) (Cell) Is it safe to contact/leave
Biographical History Form Child/Adolescent
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BEHAVIOR & ADHD SCREENING INTAKE FORM
3171 N.E. Carnegie Drive, Suite A Lee s Summit, MO 64064 P: (816) 525-2800 F: (816) 525-4077 www.summitdoctors.com BEHAVIOR & ADHD SCREENING INTAKE FORM PATIENT NAME: TODAYS DATE / / LAST FIRST MI DATE
Mental Illness and Disorders Notes
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Katarina R. Mansir, Psy.D. Licensed Psychologist PSY25417 (858) Name: Date: Presenting Concerns
Name: Date: Presenting Concerns Briefly describe what brings you to therapy. Approximately how long has this concern been bothering you? Day Week Month Several months Year Several years Most of my life
Denise E. Bruner, M.D. & Associates, P.C.
page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
ANXIETY & OCD TREATMENT CENTER OF ANN ARBOR CLIENT INFORMATION - ADULT
ANXIETY & OCD TREATMENT CENTER OF ANN ARBOR CLIENT INFORMATION - ADULT Client s Name Name you go by (if different) Gender Age Date of Birth Address City State Zip OK to leave a message? Y/N Y/N Home Phone
EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION PART I: PERSONAL INFORMATION STREET ADDRESS CITY/STATE
EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION PART I: PERSONAL INFORMATION FIRST NAME LAST NAME EMAIL PHONE # STREET ADDRESS CITY/STATE ZIP GENDER: MALE FEMALE TRANSGENER MARITAL STATUS: MARRIED