General Information

Client Name:

Phone#:

D.O.B:

Address:

Insurance Provider:

*Policy Holders Name:

*Policy Holders DOB:

Insurance Member ID:

Insurance Provider's Phone #:

Questions

How may we help you today:

Are you in Crisis (Refer to ER if Yes, no appointment): - Choose an Option - Yes No

Are you currently on psychiatric medications? If so, What are they?

Are you stable on your medications? - Choose an Option - Yes No Not Applicable

Are you currently seeing a psychiatrist? If yes, with whom and when last seen:

Are you currently seeing a therapist? If yes, with whom and when last seen:

Any Inpatient/Outpatient Treatment for Mental Health or Substance Abuse? If yes when and where:

Any History of Suicide attempt? If yes Please describe:

Do you feel you are a harm to yourself or others? If yes, any intent or plan?

Do you experience any symptoms of Depression, Anxiety, or Panic Attacks? If yes, how often?