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 / Married / Divorced / Widowed / Other: ( ) - ( ) - (Preferred Phone Number) (Other Phone Number) (Email Address) Emergency Contact: ( ) - (Name) (Relationship to Patient) (Contact Number) Employment Status: Professional Title: ( ) - Yes or No (Employer or School Attended) (Contact Number) (May we contact this number to reach you?) PRIMARY RESPONSIBLE PARTY for the patient (If self please skip to the bottom of this form and sign the agreement) Please circle one: Self / Parent / Stepparent / Legal Guardian / Power of Attorney / In-law Male Female Other / / (Responsible Party Legal Last Name) (Legal First Name) (MI) (DOB) Home Cell ( ) - ( ) - (Preferred Phone Number) (Other Phone Number) (Email Address) SECONDARY RESPONSIBLE PARTY for the patient (If self please skip to the bottom of this form and sign the agreement) Please circle one: Self / Parent / Stepparent / Legal Guardian / Power of Attorney / In-law Male Female Other / / (Responsible Party Legal Last Name) (Legal First Name) (MI) (DOB) Home Cell ( ) - ( ) - (Preferred Phone Number) (Other Phone Number) (Email Address) By signing this application I am giving my permission, as the responsible party, for the providers listed on this document and their staff operating out of Second Wind Wellness Center to contact the patient and/or myself at the provided information above regarding the care of the patient (i.e. appointments, financial matters, lab results, and medication refill information). Signature of patient age 14 years or older (Or legal representative if patient has medical guardian or power or attorney) Date 1
Insurance Information Form PRIMARY INSURANCE for the Patient (All fields below must be filled out if applicable. If the patient is not primary on the policy we must have the primary s information below) Policy Holder is: Please circle one: Self / Spouse / Parent / Stepparent / Legal Guardian / Power of Attorney / In-law, Other: If different from Patient / / (Primary Insured / Employee s Last Name) (Legal First Name) (MI) (DOB) - - (Insurance Company Name) (Plan / Group / Employer Name) (Insured Social Security Number) / / (Policy Number or Member ID Number) (Group Number) (Effective Date) SECONDARY INSURANCE for the Patient (All fields below must be filled out if applicable. If the patient is not primary on the policy we must have the primary s information below) Policy Holder is: Please circle one: Self / Spouse / Parent / Stepparent / Legal Guardian / Power of Attorney / In-law, Other: If different from Patient / / (Primary Insured / Employee s Last Name) (Legal First Name) (MI) (DOB) - - (Insurance Company Name) (Plan / Group / Employer Name) (Insured Social Security Number) / / (Policy Number or Member ID Number) (Group Number) (Effective Date) THIRD PARTY PAYER OR CASH PAYING Please give as many details as possible about who will be paying for the patient s care: 2
Application Questionnaire 1. Please select which services the patient is seeking. Therapy/Counseling Medication Management Family/Couples Counseling Group Therapy Other: 2. What is the patient s reason for seeking mental health services? (Please be as specific as possible.) 3. How were you referred to us? Doctor / Friend / Family / Website or Search Engine / Other (Circle one and please give details.) 4. Does the Patient have a Primary Care Provider? If yes, please list the name of the provider and their clinic. Yes Provider: Clinic: or No 5. Has the patient ever been or is currently being seen by a mental health provider if yes list below who have was the patient seeing? Yes, the patient is currently seeing Yes, the patient was previously seeing No 6. Would the patient or guardian be willing to sign a release of information from the patient s previous provider(s) to help us provide the best care possible? Yes or No 3
Presenting Problems & Concerns Are any of the behaviors and symptoms below something you would consider problematic: (Check all that apply) Distractibility Nightmares Homicidal thoughts Panic Attacks Other: Adult (14 and over) Intake Form Change in appetite Sadness/depression Relationship problems Sleep problems Suspicion/paranoia Social discomfort Low self-worth Seasonal mood changes Hyperactivity Eating problems Flashbacks Fear away from home Lack of motivation Loss of pleasure/interest Work/school problems Self-harm behaviors Racing thoughts Obsessive thoughts Guilt/shame Frequent arguments Impulsivity Gambling problems Hearing voices Parenting problems Withdrawal from people Hopelessness Alcohol/drug use Crying spells Excessive energy Compulsive behavior Fatigue Irritability/anger Boredom Computer addiction Visual hallucinations Sexual problems Anxiety/worry Thoughts of death Recurring, disturbing memories Loneliness Wide mood swings Aggression/fights Problems with pornography Poor memory/confusion Are your problems affecting any of the following? (Check all that apply) Handling everyday tasks Self esteem Relationships Hygiene Work/School Housing Legal matters Finances Recreational activities Sexual activity Health Yes No Questions: Have you ever had thoughts, made statements, or attempted to hurt yourself? If yes, please describe: Have you ever had thoughts, made statements, or attempted to hurt someone else? If yes, please describe: Have you recently been physically hurt or threatened by someone else? If yes, please describe: Have you gambled in the past 6 months? If yes, let us know the following: Have you ever felt the need to bet more and more money? Have you ever had to lie to people important to you about how much you gambled? Previous Mental Health Treatment Yes No Type of Treatment When? Provider/ Program What was the Treatment? Outpatient Counseling Medication (mental health) Psychiatric Hospitalization Drug/Alcohol Treatment Self-help/Support Groups Current Medications and Allergies Name of Medication Dose How is it working for you? Please list any allergies you have, medication or otherwise: 4
Please select the options that best describe your parents current and previous status: (Check all that apply) Parents legally married or living together Mother remarried: Number of times Parents temporarily separated Father remarried: Number of times Parents divorced or permanently separated Father deceased Mother deceased Have you experienced any of the following types of trauma or loss? (Check all that apply) Emotional abuse Neglect Lived in a foster home Sexual abuse Violence in the home Multiple family moves Physical abuse Crime victim Homelessness Parent substance abuse Parent illness Loss of a loved one Teen pregnancy Placed a child for adoption Financial problems Tobacco Caffeine Alcohol Marijuana Cocaine/crack Ecstasy Heroin Current Use (last 6 months) Substance Use History Past Use Substance Type Y N Frequency Amount Y N Frequency Amount Methamphetamines Other Substances: Family & Developmental History Relationship Name Age Quality of Relationship Family Mental Health Problems Who? Mother Father Stepmother Stepfather Siblings Spouse/partner Adult (14 and over) Intake Form Hyperactivity Sexually Abused Depression Bipolar Disorder Suicide Anxiety Panic Attacks Obsessive-Compulsive Anger/Abusive Schizophrenia Eating Disorder Alcohol Abuse Drug Abuse Yes No Have you had withdrawal symptoms when trying to stop using any substances? If yes, please describe: Have you ever had problems with work, relationships, health, the law, etc. due to your substance use? If yes, please describe: 5
Adult (14 and over) Intake Form Medical Information Date of last physical exam: / / Who is the Provider Completed the Exam? Have you experienced any of the following medical conditions during your lifetime? (Check all that apply) Allergies Asthma Headaches Abortion Sleep disorder Seizures Vision problems High fevers Meningitis Chronic pain Miscarriage Sexually transmitted disease Stomach aches Hearing problems Surgery Serious accident Dizziness/fainting Diabetes Head injury Other: Please list any CURRENT health concerns: Miscellaneous Information Military Service Yes No Have you been/are you currently in the military? Branch: Date of Discharge: / / Type of Discharge: Rank: Yes No Were you in combat? Legal Yes Yes No No Sexual Orientation / Social & Cultural / Education & Interests Sexual Orientation Please describe your sexual orientation (Check all that apply) This section is optional, if you wish not to disclose please leave blank. Gay, Lesbian, Homosexual Straight, Heterosexual Bisexual Other: Social & Cultural Networks Please describe your social support network (Check all that apply) Family Neighbors Friends Students Co-workers Support/Self-Help Group Community Group Religious/Spiritual Center which one? How important are spiritual matters to you? Not at all Little Somewhat Very much Yes No Would you like spiritual/religious beliefs to be incorporated into your counseling? To which cultural or ethnic group do you belong? Education & Interests Please fill out each section as it best applies to you. Highest Level of Education Completed: Degree: Describe any special areas of interest or hobbies (art, books, physical fitness, etc.): Please describe your strengths, skills, and talents? Have you ever been convicted of a misdemeanor or felony? If yes, please explain Are you currently involved in any divorce or child custody proceedings? If yes, please explain 6