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