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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?
Ok to leave a message with a family member?
Ok to leave a message at work (voicemail)?
Email
Ok to leave a message with a family member?
Date of Birth
Age
Guardianship (adults when applicable)
Role in Family Unit
Gender
Marital Status
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

How did you hear about us?
Referral Source
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.


Primary Care Physician Contact Authorization
Primary Care Physician's Name:
Address
Telephone Number:
Fax Number:
I authorize OCA (Please Check One)
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.

Signature
By electronically signing below, you acknowledge that you have read and understand this document.

Electronically Signed By