Patient Information
- Full Name: _________________________ Date: //___
- Date of Birth: //___ Age: ____ Gender: ________
- Address: ________________________________________________
- Phone: (Home) ____________ (Cell) ____________
- Email: ________________________________________________
- Emergency Contact: _________________ Phone: _____________
Insurance Information
- Primary Insurance: ______________________________________
- Policy Number: ________________________________________
- Group Number: ________________________________________
Mental Health History
Previous Mental Health Treatment
- Have you previously received psychiatric care? □ Yes □ No
- Previous psychiatrist(s): _________________________________
- Previous diagnoses: _____________________________________
- Current medications: ____________________________________
Current Symptoms (check all that apply)
□ Depression
□ Anxiety
□ Panic attacks
□ Sleep problems
□ Mood swings
□ Concentration difficulties
□ Suicidal thoughts
□ Other: _______________
Medical History
- Primary Care Physician: _________________________________
- Current medical conditions: ______________________________
- Allergies: ____________________________________________
- Family history of mental illness: __________________________
Substance Use
- Alcohol use: □ Never □ Occasionally □ Regularly
- Tobacco use: □ Never □ Previously □ Currently
- Other substance use: ___________________________________
Authorization
I certify that the above information is accurate and complete:
Signature: ______________________ Date: //___