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info@ocabehavioral.com
Phone
(732) 477-1020
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Initial Psychiatric History and Examination
Demographic Information:
First Name
Middle
Last Name
Address
City
State/Zip
Home Phone
Cell Phone
Work Phone
Ext
Ok to leave a message on machine at home?
- Choose an Option -
Yes
No
Ok to leave a message with a family member?
- Choose an Option -
Yes
No
Ok to leave a message at work (voicemail)?
Email
Ok to leave a message with a family member?
- Choose an Option -
Yes
No
Date of Birth
Age
Guardianship (adults when applicable)
Role in Family Unit
- Choose an Option -
Mother
Daughter
Son
Husband
Other
Gender
- Choose an Option -
Male
Female
Marital Status
- Choose an Option -
Single
Married
Divorced
Separated
Employer or School (if applicable)
Employment Status
Occupation
Address
Insurance Policy Information
Insurance Company/HMO
Patient ID Number/Member ID
Group Number
Policy Holder's Name
Policy Holder's DOB
Relationship to Policy Holder (Ex: Spouse, Child, Guardian, etc)
Claims Mailing Address
City
State/Zip
Phone
Emergency Contact:
First Name
Last Name
Relationship to Patient
Address
City
State/Zip
Home Phone
Cell Phone
Confirm
I authorize OCA Behavioral Health Services to contact the above named person in case of an emergency.
How did you hear about us?
Referral Source
Insurance
Internet
Friend
Mental Health Therapist/MD
Facility
Referral Detail
Pharmacy Information
Pharmacy Name
Address
Phone
Psychiatric Medications
List all psychiatric medications that you are currently taking (Name of Medication & Dosage/Frequency)
Patient-Physician Authorizations and Agreements
Patients Name:
Medical Insurance - I authorize the medical insurance company below to pay directly for the above provider’s services. I, however, understand that both the person who signs below is responsible for all my fees, including any fees not paid by insurance company.
Financial Responsibility
I understand and agree that I am responsible for the fees to OCA Behavioral Healthcare Services LLC, including any fees not paid by medical insurance. That if the account is not paid when due, reasonable collection and court costs will be paid by the under signed.
I am responsible for $100 LATE CANCELLATION and "NO-SHOW" fees resulting from appointments not kept or cancelled without a 24-hour notice; ALL fees for outpatient services must be paid at the time services are rendered.
I agree
Primary Care Physician Contact Authorization
Primary Care Physician's Name:
Address
Telephone Number:
Fax Number:
I authorize OCA (Please Check One)
To release any applicable mental health information to my primary care physician (PCP) above
To release any applicable substance abuse information to my PCP named above
To release only medical information to my PCP named above
Not to release any information to my PCP named above
I do not have a PCP at this time
I may revoke this authorization at any time except to the extent that action has been taken in reliance upon it. If I do not revoke this authorization, it will expire one (1) year after I have terminated treatment.
I understand
Signature
By electronically signing below, you acknowledge that you have read and understand this document.
Electronically Signed By
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