problems/medications: Current supplements/vitamins/herbs: Past medical problems/medications: Other doctors/clinics seen regularly:
|
|
|
- Marjorie Cox
- 5 years ago
- Views:
Transcription
1
2 Main Purpose of the consultation (Please give a brief summary of the main problems) What happened to make you seek evaluation at this time? MEDICAL HISTORY Current medical Prior Attempts to correct the problem/prior psychiatric history: (Please include contact with other professionals, medications, types of treatment, etc.) problems/medications: Current supplements/vitamins/herbs: Past medical problems/medications: Other doctors/clinics seen regularly: Any history of hitting your head, even if you don t lose consciousness? (e.g. car accident, hitting head on monkey bars, playing football, etc): Have you ever lost consciousness?
3 Have you been exposed to toxic substances? (e.g. furniture refinishing, agent orange, pesticides, etc) Ever had any seizures or seizure like activity? Prior hospitalizations (place, cause, date, outcome): Prior abnormal lab tests, X-rays, EEG, etc: Allergies/drug intolerances (describe): Do you have mold in your house? Do you have a carbon monoxide detector in your house? Yes No Do you have silver amalgam dental fillings? Yes No Present Height Present Weight Current Life Stresses: (include anything that is currently stressful for you, examples include relationships, job, school, finances, children) Prenatal and birth events: Your parents' attitudes toward their pregnancy with you Pregnancy complications (bleeding, excess vomiting, medication, infections, x-rays, smoking, alcohol/drug use, etc Any birth problems, trauma, forceps or complications? Sleep behavior: Is it hard for you to make yourself go to bed? Yes No Explain: How long does it take you to fall asleep? Do you stay asleep? Yes No Explain: Do you snore? Yes No Do you have sleepwalking, nightmares, night terrors, recurrent dreams, restless legs, talking in your sleep? School History: Last grade completed Last school attended Average grades received Specific learning disabilities
4 Learning strengths Any behavior problems in school? What have teachers said about you? Employment History: (summarize jobs you've had, list most favorite and least favorite) Any work-related problems? What would your employers or supervisors say about you? Military History? Ever Any Legal Problems? Alcohol and Drug History: (Please list age started and types of substances used through the years and any current usage. Also, describe how each of these substances made you feel; what benefit you got from them.). These include alcohol (hard liquor, beer, wine), marijuana or hash, prescription tranquilizers or sleeping pills, inhalants (glue, gasoline, cleaning fluids, etc.), cocaine or crack, amphetamines or crank or ice, steroids, opiates (heroin, codeine, morphine or other pain killers), barbiturates, hallucinating drugs (LSD, mescaline, mushrooms, PCP).
5 Do you or have you ever experienced withdrawal symptoms from alcohol or drugs? Has anyone told you they thought you had a problem with drugs or alcohol? Have you ever felt guilty about your drug or alcohol use? Have you ever felt annoyed when someone talked to you about your drug or alcohol use? Have you ever used drugs or alcohol first thing in the morning? Caffeine use per day (caffeine is in coffee, tea, sodas, chocolate) Nicotine use per day, past and present, (nicotine is in cigarettes, cigars, tobacco chew) Sexual history: (answer only as much as you feel comfortable) Primary Sexual Orientation: Gay, Straight, Bisexual Age at the time of first sexual experience: Number of sexual partners: Any history of sexually transmitted disease? History of abortion? History of sexual abuse, molestation or rape? Current sexual problems? Any history of being physically or sexually abused? Yes No FAMILY HISTORY Family Structure (who lives in your current household, please give relationship to each): Current Marital or Relationship Satisfaction Significant Life Events (include past and current marriages, separations, divorces, deaths, traumatic events, losses, abuse, etc.)
6 Natural Mother's History: age occupation School: highest grade completed Learning problems Behavior problems Marriages Medical Problems Childhood atmosphere (family position, abuse, illnesses, etc) Has mother ever sought psychiatric treatment? Yes No If yes, for what purpose? Mother's alcohol/drug use history Have any of your mother's blood relatives ever had any learning problems or psychiatric problems including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify) Natural Father's History: age occupation School: highest grade completed Learning problems Behavior problems Marriages Medical Problems Childhood atmosphere (family position, abuse, illnesses, etc) Has father ever sought psychiatric treatment? Yes No If yes, for what purpose?
7 Father's alcohol/drug use history: Have any of your father's blood relatives ever had any learning problems or psychiatric problems including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify) Siblings: Name Age relationship to patient Problems Strengths Cultural/Ethnic Background: Describe your relationships with friends: Describe yourself: Describe your strengths: What would you like to accomplish in your meeting?
8 Primary Insurance Information: Insurance Company name: Policy Number or Contract #: Group #: Social Security number of Policyholder: Employer Name: Name of Policyholder: Birth Date of Policyholder: Address of policyholder: City: State: Zip: Phone: Secondary Insurance Information: Insurance Company name: Policy Number or Contract #: Group #: Social Security number of Policyholder: Employer Name: Name of Policyholder: Birth Date of Policyholder: Address of policyholder: City: State: Zip: Phone: I understand as the primary responsible party, I will pay for all portions of charges that my insurance Company does not cover. I authorize the Center for Family Development to electronically transmit the claim to the insurance company, send any necessary documentation and discuss this case including diagnosis and other information from the clinical record with the insurance companies listed. I authorize my insurance company to send benefits directly to the Center for Family Development. In case of canceled appointments, I agree to provide 24 hours notice to the Center for Family Development or be responsible for a $30.00 missed appointment fee. Signature of Responsible Party: Date:
9
10
11
PATIENT IDENTIFICATION: Name: First Appointment Date: Birth Date: Address: City State Zip Home Phone #: Work #: Cell #: REFERRAL SOURCE: Referred By:
Andrew E. Leifer, M.D., P.C. 1202 Bergen Parkway, Suite 211 Evergreen, Colorado 80439 General Adult Psychiatry Outpatient and Hospital Care Medical Consultation-Liaison Service Telephone (303) 674-6074
ADD/ADHD Patient Intake Form. Patients age 18 years or older
Lisa Sachdev, D.O. ADD/ADHD Patient Intake Form Patients age 18 years or older Please fill out the following questionnaire prior to your first appointment. You must be completely honest and detailed in
ADD/ADHD Assessment. for patients age 18 years or older. Name: Date of Birth: Age: Sex: Today s Date:
Lisa Sachdev, D.O. ADD/ADHD Assessment for patients age 18 years or older In order for us to be able to fully evaluate you, please fill out the following questionnaire to the best of your ability. We realize
Name: Date: Gender: Family and Social. Family Constellation
Name: Date: Gender: Age: Date of Birth: Race: Family and Social Family Constellation First Name Or Initials Parents (indicate biological or other): Age Gender Marital Status Occupation Education If deceased,
PERSONAL HISTORY What are your strengths? (i.e. skills, positive qualities or characteristics) Hobbies/Extracurricular Activities (Please list): ETHNI
Date of Assessment ADULT PSYCHOSOCIAL HISTORY/INITIAL THERAPY INTAKE FORM Identifying Information: Name: Address: Age: D.O.B: Phone Number: Race: Gender: Religious Affiliation(optional): Current Household
Pinkston Psychology, LLC Ph. (318) Fx. (318) Completed this form Patient Spouse Parent Other
Pinkston Psychology, LLC Ph. (318) 553-5099 paula@pinkstonpsychology.com Fx. (318) 553-5338 ADULT HISTORY FORM Date Completed this form Patient Spouse Parent Other Patient s Name Date of Birth Age Sex
Name: Gender: male female Age: Date of birth: / / Preferred phone: cell home work other. Alternate phone: cell home work other.
Casey Alexander Paleos, MD NEW CLIENT INTAKE FORM 775 Park Avenue, Suite 200-2 Huntington, NY 11743 tel 631-629-5887 Date: / / BASIC INFORMATION Name: Gender: male female Age: Date of birth: / / Preferred
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:
Client Information Form
Client Information Form General Information Date: Name: Date of Birth: Age: Current Address: Home Phone: Cell Phone: Best number and time to reach you directly: Can I leave a message at either or both
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
DRUG AND ALCOHOL QUESTIONNAIRE
DRUG AND ALCOHOL QUESTIONNAIRE Part I. Substance Abuse History Ever Used? Ever a Problem? Age of 1 st Use When last used? Alcohol Yes No Yes No Barbiturates or Yes No Yes No other sleeping pills Benzodiazepines
710 Oakfield Drive, Suite 153 P: (813) Brandon, FL F: (813) Client Information - Adult form
710 Oakfield Drive, Suite 153 P: (813) 654-053 Brandon, FL 33511 F: (813) 653-3963 Today s date: Client Information - Adult form Note: If you have been a patient here before, please fill in only the information
Puget Sound Behavioral Medicine TH AVE SE MERCER ISLAND, WA PHONE/FAX 206/ ADULT QUESTIONNAIRE
Puget Sound Behavioral Medicine 2553 76 TH AVE SE MERCER ISLAND, WA 98040 PHONE/FAX 206/275-0702 ADULT QUESTIONNAIRE To help us to fully evaluate your concerns, please fill out the following intake form
Child Psychiatry Intake Questionnaire
Child Psychiatry Intake Questionnaire In order for us to be able to fully evaluate your child, please fill out the following questionnaire to the best of your ability. We realize there may be information
Alcorn & Allison. clinical associates **C O N F I D E N T I A L**
Alcorn & Allison clinical associates **C O N F I D E N T I A L** ADULT INITIAL INTAKE ASSESSMENT *Please fax your completed form to 630.469.4911 prior to your first session. If you are unable to do so,
General Information. Name Age Date of Birth. Address Apt. # City State Zip. Home Phone Work Phone. Social Security Number Marital Status
Accredited Member Center of The American Academy of Sleep Medicine 400 Riverside Drive, Suite 1500, Bourbonnais, IL 60914 Phone (815) 933-2874 Fax (815) 939-9413 www.riversidemc.net/sleep General Information
Sonja Benson, Ph.D., PLLC Licensed Psychologist
Sonja Benson, Ph.D., PLLC Licensed Psychologist Date_ Referred by Name Date of Birth Social Security # Address_ City State Zip code Daytime Phone Nighttime Phone Cell Phone Email Male( ) Female ( ) Ethnicity
Client Information Form
Today s Date: Client Information Form Note: If you have been a client here before, please fill in only the information that has changed. If you are seeking services as a couple, each member must complete
ADULT QUESTIONNAIRE. What have you been told with regard to the problem?
1 ADULT QUESTIONNAIRE Please complete this 2-sided questionnaire. Write N/A when a question is not applicable. Date: Full Name: Birth Date: Age: Sex: Home Address: Telephone: City: State: Zip Code: Email:
PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:
SECTION 2: CURRENT CONCERNS Briefly describe the current concerns you would like to discuss with your counselor:
Page 1 Amarillo College Counseling Center Intake Packet The following information is needed to best serve you. Please clearly print your response to each question. SECTION I: IDENTIFYING INFORMATION Today
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
ADULT HISTORY QUESTIONNAIRE
ADULT HISTORY QUESTIONNAIRE Date: Full Name: Date of Birth: If applicable, please complete the following: Partner s Name: Partner s Age: Partner s Occupation: IF YOU HAVE CHILDREN PLEASE LIST THEIR NAMES
Baptist Health Floyd 1850 State Street New Albany, IN Sleep Disorders Center Lung & Sleep Specialists. Date of Birth: Age:
Page 1 of 7 GENERAL INFORMATION Name: Date of Birth: Age: Social Security #: Sex: Height: Weight: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Employer s Name: Marital Status: Married
Child and Youth Background Information
Child and Youth Background Information CHILD S NAME: SUBSTANCE USE HISTORY (for ages 12 and older or if applicable) Substance Type Current Use (last 6 months) Past Use: Please check and complete all that
ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Work phone: Cell phone: Ok to leave message? Yes No Ok to leave message? Yes No Ok to leave message? Yes No Email:
PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
SANDSTONE PSYCHOLOGICAL PRACTICE
SANDSTONE PSYCHOLOGICAL PRACTICE Christina L. Aranda, Ph.D. & Janell M. Mihelic, Ph.D. CONTACT INFORMATION New Client Questionnaire Name: Date: Date of Birth: Age: _ Address: Preferred Phone Number: Type:
People In Need Adult Intake Information Form (18 years old and up)
People In Need Adult Intake Information Form (18 years old and up) Date: Name: Client Case # Sex: Date of Birth: Social Security Number: - - Home Address: Work Address: Employer: Occupation: Referred by:
1811 B Green Circle Valdosta, GA Do you have any problems at this time?
TVC 1811 B Green Circle Valdosta, GA 31602 229-244-9688 Name: Date: Do you have any problems at this time? Please check any symptoms that describe how you feel, think, or behave currently or during the
Driftwood Psychological Services 664 Scranton Rd., Suite 201 Brunswick, GA Phone:
1 Driftwood Psychological Services 664 Scranton Rd., Suite 201 Brunswick, GA 31525 Phone: 912-230-2436 drtara@driftwoodpsych.com Client name Date ADULT HISTORY FORM Presenting problems Why I came for counseling:
CLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:
CLIENT HISTORY CLIENT LEGAL NAME: DATE: CLIENT PREFERRED NAME: FAMILY & SOCIAL BACKGROUND Please list and describe your current family members (immediate, extended, adopted, etc.) and/or other members
5975 Parkway North Blvd., Suite D 3060 Royal Blvd. South, Suite 110 Cumming, GA Alpharetta, GA 30022
1 5975 Parkway North Blvd., Suite D 3060 Royal Blvd. South, Suite 110 Cumming, GA 30040 Alpharetta, GA 30022 (p) 404-388-3909 www.focusforwardcc.com (f) 678-712-1945 info@focusforwardcc.com ADULT HISTORY
Please check all the behaviors and symptoms that you consider problematic:
Name Date Address Phone # Date of birth Email address Social Security Describe the issue that brought you here today: Please check all the behaviors and symptoms that you consider problematic: Distractibility
A New Tomorrow Behavioral Health Services
A New Tomorrow Behavioral Health Services Tara L. Corbett MS, LPC Jenais Y. Means MA, LPC-I Linda L. Leech PhD, LPC, LPC-S Natasha Moseng MS, LPC-I 2635-A Hardee Cove, Sumter, S.C. 29150 Phone: (803) 883-4981
Counseling Service Personal Information Form. Name: Preferred Name: Can your preferred name be updated for all LC Health and Wellness offices?
Date: Counseling Service Personal Information Form Name: Preferred Name: Can your preferred name be updated for all LC Health and Wellness offices? Yes No Phone number: May the Counseling Service leave
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
Note: If you have been a client here before, please fill in only the information that has changed.
Today s date: LMFT#100342 Note: If you have been a client here before, please fill in only the information that has changed. A. Identification Your name: Date of birth: Age: Nicknames or aliases: Home
Nebraska Bariatric Medicine 8207 Northwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY
Nebraska Bariatric Medicine 8207 rthwoods Dr., Suite 101 Lincoln, NE 68505 MEDICAL HISTORY Name Today s Date The following page allows you to complete what we call a weight timeline. This is a very valuable
Many drugs of abuse are illegal drugs. Possessing, using, buying, or selling these drugs is illegal for people of any age.
1 Chapter 12 Section 1 Objectives List six ways illegal drug use can be dangerous. State five reasons a person might try illegal drugs. Identify the reason drug abuse is especially dangerous to teens.
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
Henrike B. Kroemer, Ph.D. ADULT HISTORY FORM
INTRODUCTORY INFORMATION Henrike B. Kroemer, Ph.D. ADULT HISTORY FORM Date completed Name Date of Birth (last) (first) (middle) Address Telephone: home work cell Email address Soc Sec # Gender Marital
SLEEP QUESTIONNAIRE. Please briefly describe your sleep or sleep problem:
SLEEP QUESTIONNAIRE Your answers to the following questions will help us to obtain a better understanding of your sleep problems. Please answer every question to the best of your ability. It is helpful
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
New Client Information. address: Date of Birth:
Milwaukee Area Psychological Services, S.C. (MAPS) 401 E. Kilbourn Avenue, Suite 402 Milwaukee, WI 52302 414-269-8660 (phone) 414-269-8656 (fax) New Client Information Your responses to the following questions
Behavior Health Admission Information Form. Name Date
Behavior Health Admission Information Form Name Date What symptoms are you experiencing? Depressed Mood Anxiety Agitation Hopelessness Suicidal Thoughts Worthlessness Guilt Anger Difficulty Concentrating
New Patient Evaluation Form
New Patient Evaluation Form Alfred Tennant, DDS TMJ, Facial Pain, Dental Sleep Medicine 33 Davis Blvd Tampa, FL 33606 Fax (813)658-6254 Phone (813)743-2352 Please complete pages 1-8 and circle choices
Christina Pucel Counseling 416 W. Main St Monongahela, PA /
ADULT INTAKE Name: Gender: M F DOB: Address: City: State: Zip: Telephone: Home Mobile Highest Level Education: Occupation: Emergency Contact: Relationship: Phone: Referred by: Family Members: Name Gender
Becky Nickol, NCC, LMHC Licensed Mental Health Counselor, MH Wood Lake Drive Maitland, Florida
Becky Nickol, NCC, LMHC Licensed Mental Health Counselor, MH 8569 240 Wood Lake Drive Maitland, Florida 32751 407-831-7783 becky@beckynickol.com Adult Biopsychosocial Assessment General Information Date:
Psychiatric Evaluation Intake Form
Psychiatric Evaluation Intake Form Patient Contact Information Patient Name: Date of Birth: Age: Last First MI Address: Contact phone number: Email address: Emergency Contact/Number/Relationship: Primary
Jeffrey E. Lazarus, M.D. Board Certified in Pediatrics Child & Adolescent Clinical Hypnosis & Biofeedback. Headache Questionnaire
Jeffrey E. Lazarus, M.D. Board Certified in Pediatrics Child & Adolescent Clinical Hypnosis & Biofeedback 1220 University Drive, Suite 104 Menlo Park, California 94025 www.jefflazarusmd.com Headache Questionnaire
PSYCHOLOGICAL EVALUTAION QUESTIONNAIRE
PSYCHOLOGICAL EVALUTAION QUESTIONNAIRE The purpose of this questionnaire is to obtain an understanding of your life experience and background which is part of the evaluation process. Please bring this
FOR SECURITY REASONS, WE DO NOT ALLOW OCCUPIED VEHICLES IN OUR PARKING LOT.
Pain & Wellness of Centers of Georgia FOR SECURITY REASONS, WE DO NOT ALLOW OCCUPIED VEHICLES IN OUR PARKING LOT. I understand that if I receive a ride here, the people that accompany me MAY NOT wait in
Patient Information. Name: Date of Birth: Address: Number & Street City State Zip Code. Home Number: ( ) Cell Number: ( )
Patient Information Name: Date of Birth: Age: Address: Number & Street City State Zip Code Home Number: ( ) Cell Number: ( ) Social Security Number: Marital Status: Religion: Race: Height: Weight: Sex:
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
Adult Health History Form Preferred Name: 1
Adult Health History Form Preferred Name: 1 Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are uncomfortable with
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:
SAMPLE. Date of Birth: Age: Gender: Woman: Man: Transgender: Transman: Transwoman: Gender Nonconforming: Other:
Patient Intake Questionnaire Note: This is a sample intake questionnaire which includes a wide variety of potential questions that can be asked of new clients during the intake process. Providers are encouraged
MN Couple Therapy Center 1611 County Road B, Suite 204 Roseville, MN
MN Couple Therapy Center 1611 County Road B, Suite 204 Roseville, MN 55113 651.340.4597 FULL NAME DATE DOB Presenting Problem 1. What is/are the reason(s) you are seeking therapy today? 2. Did a specific
*IN10 BIOPSYCHOSOCIAL ASSESSMENT*
BIOPSYCHOSOCIAL ASSESSMENT 224-008B page 1 of 5 / 06-14 Please complete this questionnaire and give it to your counselor on your first visit. This information will help your clinician gain an understanding
Intake Questionnaire For New Adult Patients
Intake Questionnaire For New Adult Patients This brief questionnaire will help me get to know you better in order to provide the best possible care for you. Please answer as honestly and completely as
PATIENT NAME: M.R. #: ACCT #: HOME TEL: WORK TEL: AGE: D.O.B.: OCCUPATION: HEIGHT: WEIGHT: NECK SIZE: GENDER EMERGENCY CONTACT: RELATIONSHIP: TEL:
SLEEP DISORDERS INSTITUTE HOSPITAL: DePaul Building Street Address City, State Zip Tel: (202) 555-1212 Fax: (202) 555-1212 SLEEP QUESTIONNAIRE PATIENT NAME: M.R. #: ACCT #: STREET ADDRESS: CITY: STATE:
Adult Neuropsychological Questionnaire
Adult Neuropsychological Questionnaire Note: If you need more space for any of the answers, please use the back page(s) to elaborate. Name: Date of Birth: Age: Sex: Highest Grade/Degree Completed: Dominant
CHECKLIST OF CONCERNS AND HISTORY FORM
CHECKLIST OF CONCERNS AND HISTORY FORM Name: Date: Please mark any items that apply to you. PROBLEM AREAS--CAREER, SCHOOL Career concerns, goals, and choices Unemployment Job stress School problems Learning
ELEMENTAL CENTER MENTAL HEALTH INTAKE FORM
1 Please complete all information on this form. It may seem long, but most of the questions require only a check, so it will go quickly. Thank You! Personal Information First Name Last Name Gender DOB
Steve Barns & Associates The Counseling Center of Denton Bible Church Christian Counseling Services Individual, Marriage, & Family
: Last First MI Male Female / / Age Email: @ Home: ( ) - Cell: ( ) - Address: Street (or P.O. Box) Apt. # City State Zip Code Emergency contact: ( ) - Place of Employment: How long? yrs. mos. Current Marital
Lyris Bacchus Steuber, MS, LMFT MT Harley Lester Lane Apopka, FL Ph: , Fax:
Lyris Bacchus Steuber, MS, LMFT MT 2075 515 Harley Lester Lane Apopka, FL 32703 Ph: 407 417 7770, Fax: 407 862 4820 Please complete the following so I can have a better understanding of how I can help
ALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION
ALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION LEGAL Name Date of Birth (must match insurance card) Address City State Zip Mailing Address City State Zip (If different) Phone: Cell Home Appt. reminders
Brunswick Pulmonary and Sleep Medicine Lawrence Davanzo, DO, FCCP 49 Veronica Ave, Somerset, NJ Phone# Fax#
REGISTRATION FORM (Please Print) Today s date: PCP: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid If not, what is
Pediatric Sleep History
Fax 423-431-2983 Pediatric Sleep History Patient/ Child s Name: Date of Birth: Parent Name: Last 4 of Social Security No: Gender: Male Female Height: Weight: Age: Race: Street Address: City: State: Zip:
6800$5< /,)(7,0( ',$*126(6 &+(&./,67 'DWH RI &XUUHQW BBBB BBBB BBBBBB
Criteria for Probable Diagnosis: 1. Meets criteria for core symptoms of the disorder. 2. Meets all but one, or a minimum of 75% of the remaining criteria required for the diagnosis 3. Evidence of functional
SLEEP QUESTIONNAIRE. Name: Home Telephone. Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: Pharmacy & Phone #:
q JHMCE q JHS q SMEH SLEEP QUESTIONNAIRE 1. DEMOGRAPHIC DATA Name: Home Telephone Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: 2. PHYSICIAN INFORMATION Name of Primary
Name: Date: Who referred you? Current Psychiatrist: Clinical Information:
LIFE HISTORY QUESTIONNAIRE Adult The purpose of this questionnaire is to obtain an understanding of your life experience and background. Then we can begin to develop a comprehensive treatment program suited
Intake Form. Presenting Problems and Concerns. When did it start and how does it affect you:
Intake Form Name: Date: Presenting Problems and Concerns Describe the problem that brought you here today: When did it start and how does it affect you: Estimate the severity of the above problem: Mild
CARD TOBACCO: Cigarettes, E- Cigarettes, Cigars, Tobacco Pipe, Chewing Tobacco, Snuff
CARD 1 1. TOBACCO: Cigarettes, E- Cigarettes, Cigars, Tobacco Pipe, Chewing Tobacco, Snuff 2. ALCOHOL: Beer, Wine, Liquor 3. MARIJUANA: Grass, Pot, Hashish, Hash, Hash Oil, Weed, Ganja, Marijuana Edibles
Sleep Center of Willmar LLC
Sleep Center of Willmar LLC 1801 19 th Avenue South West Willmar, MN. 56201 320-441-2104 (telephone) 320-441-2052 (facsimile) Welcome Our staff understands that quality care and patient comfort go hand
Ashok K. Modh, M.D., F.C.C.P. Naishadh K. Mandaliya, M.D., F.C.C.P. Jerges J. Cardona, M.D. Nirav B. Patel, M.D.
Ashok K. Modh, M.D., F.C.C.P. Naishadh K. Mandaliya, M.D., F.C.C.P. Jerges J. Cardona, M.D. Nirav B. Patel, M.D. Dear, Your physician has requested that you be scheduled for a sleep study. Your appointment
MINOR CLIENT HISTORY
MINOR CLIENT HISTORY CLIENT NAME: DATE: FAMILY & SOCIAL BACKGROUND: Please list and describe your child s or teen s current family members (immediate, extended, adopted, etc.) NAME RELATIONSHIP AGE OCCUPATION
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process.
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process. PATIENT CONTACT INFORMATION Name Age Date of birth Phone ( ) Mailing
Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC
Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC aylacarter@fullcirclepsychotherapy.org www.fullcirclepsychotherapy.org (253) 686-4681 Name (First, Middle, last): Birthdate: Age: Gender: Sexual Orientation:
Sleep History Questionnaire. Sleep Disorders Center Duke University Medical Center. General Information. Age: Sex: F M (select one)
Sleep History Questionnaire Sleep Disorders Center Duke University Medical Center Part I: General Information Name: Address: Date: Phone: Age: Sex: F M (select one) Education (years of school): Occupation:
Medications. New Patient Registration. Billing and Insurance. Phone Calls. Prescription Refills. Lab Results and Test Results
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints
PATIENT INTAKE: MEDICAL HISTORY. Name. Address. Phone (W) (H) (C) DOB Age SS# Emergency Contact. Relationship to patient Phone
PATIENT INTAKE: MEDICAL HISTORY Name Address Phone (W) (H) (C) DOB Age SS# Emergency Contact Relationship to patient Phone Primary care physician Phone Have you ever had an EKG? Y N Date Current or past
Part I. Demographics. Part II. Presenting Problem. Who referred you to WellStar Psychological Services?
Part I. Demographics Today s Date Current Time : Patient s Name (Last) (First) (MI) Patient s Date of Birth Patient s Gender Female Male Patient s Address Primary Phone Ok to leave a message? Email Address
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
PATIENT HISTORY DATA FORM Psychiatric, Health and Wellness, LLC 810 Michael Drive, Suite L Chesterton, IN NAME
PATIENT HISTORY DATA FORM Psychiatric, Health and Wellness, LLC 810 Michael Drive, Suite L Chesterton, IN 46304 PRINT THIS FORM, COMPLETE AND BRING WITH YOU (DO NOT COMPLETE ONLINE) : NAME: LAST FIRST
NIDA-Modified ASSIST Prescreen V1.0 1
NIDA-Modified ASSIST Prescreen V1.0 1 F Name:... Sex ( ) F ( ) M Age... Interviewer... Date.../.../... Introduction (Please read to patient) Hi, I m, nice to meet you. If it s okay with you, I d like to
PATIENT SLEEP QUESTIONNAIRE
PATIENT SLEEP QUESTIONNAIRE Name: Date of Birth: Today s Date Primary Care Physician Telephone # Physician ordering test (Other than PCP): Physician s Tel. #: _ Age: Years Height: Feet Inches Weight: Lb
Journey to Truth Counseling
ADULT / COUPLE INTAKE FORM (Please Print) Date: / / Social Security # Date of birth: Age: Mr. Ms. Dr. Mrs. Miss. Rev. Full Name (Last) (First) (Middle) Parent/Guardian/Power of Attorney: (if applicable)
SLEEP DISORDERS INVENTORY
1090 Amsterdam, 17th Floor New York, New York 10025 212-994-5100 Toll Free: 888-SLEEP-NY Fax: 212-994-5101 SLEEP DISORDERS INVENTORY Gary K. Zammit, Ph.D., Stephen Lund, M.D., Joseph Ghassibi, M.D., Kathleen
Associates of Behavioral Health Northwest CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT
CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT Name: Date: I. PRESENTING PROBLEM What events or stressors led you to seek therapy at this time? Check all that apply. Mood difficulties (i.e. sad or depressed
Physical Issues: Emotional Issues: Legal Issues:
Men s Facility 1119 Ferry Street Lafayette, IN 47901 Phone: (765) 807-0009 Fax: (765) 807-0030 Hope Apartments 920 N 11th St. Lafayette, IN 47904 Phone: (765) 742-3246 Fax: (765) 269-9110 APPLICATION FOR
05/26/2011 Page 1 of 15
Number of IYS 2010 Respondents N Total Grade 198 203 401 Avg Age N Avg How old are you? 11.9 198 13.9 203 Gender % N % N Female 4 96 5 115 Male 5 99 4 87 Race/Ethnicity N % N % N White 8 165 8 176 Black
05/26/2011 Page 1 of 15
Number of IYS 2010 Respondents N Total Grade 101 102 203 Avg Age N Avg How old are you? 11.8 101 13.7 102 Gender % N % N Female 4 43 5 52 Male 5 57 4 50 Race/Ethnicity N % N % N White 9 97 9 99 Black /
05/27/2011 Page 1 of 15
Number of IYS 2010 Respondents N Total Grade 218 194 412 Age Avg N Avg How old are you? 11.9 218 13.8 193 Gender % N % N Female 5 112 5 103 Male 4 99 4 88 Race/Ethnicity N % N % N White 7 164 8 158 Black
ALCOHOL/DRUG ASSESSMENT FORM
ALCOHOL/DRUG ASSESSMENT FORM DEMOGRAPHIC INFORMATION Date Client s Name Age Date of Birth Address How long have you lived at this address? Type of residence (Apt. Home, Duplex, Etc.) Rent? Own? With whom
Occupation: Usual Work Hours/Days: Referring Physician: Family Physician (PCP): Marital status: Single Married Divorced Widowed
Name Social Security No. Last First MI Address Phone No. ( ) City State Zip Secondary No. ( ) Date of Birth Sex (M/F) Race Email County Primary Care Marital Status Single Divorced Married Widowed Employer
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
11/04/2011 Page 1 of 16
Survey Validity % N Invalid 5 Valid 96% 116 Valid surveys are those that have 4 or more of the questions answered, report no derbisol use, and indicate that the respondent was honest at least some of the
Humanistic Psychological Services 831 Alamo Drive, Suite 5C, 6B, 6C Vacaville, CA Phone: (707) FAX: (707)
Humanistic Psychological Services 831 Alamo Drive, Suite 5C, 6B, 6C Vacaville, CA 95688 Phone: (707) 624-9767 FAX: (707) 471-4140 Intake Paperwork for Adult Today s Date Referred By Please take time to