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Patient's Information

All fields are required. Please answer N/A if unapplicable and a team member will confirm with you.

Name

First *required

Last *required

DOB *required

Race *required‍

Ethnicity *required

SSN *required

Insurance Provider *required

Group *required

Subscriber name *required

Subscriber DOB *required

What are they struggling with? Any substance use? *required

Any history of aggression? Any property destruction? Legal issues? *required

Has the client been hospitalized or in treatment (IOP/PHP/RTC) in the past for mental health issues or overdose? If so, provide why/when/where and any records you can provide us. Any psych testing/can you provide the test results? *required

Who does the client live with? *required

Is the client on medications? If so, which meds and doses? Any current diagnoses? *required

Current treatment providers

Therapist name *required

Therapist phone number *required

Psychiatrist name *required

Psychiatrist phone number *required

Primary physician name *required

Primary physician phone number *required

Dentist name *required

Dentist phone number *required

Schooling

Is the client enrolled in school? *required

Where? *required

Grade? *required

504/IEP? *required

Contact? *required

Contact's Information

Name

First *required

Last *required

DOB *required

Phone number *required

Email *required

Relationship to patient *required

Address Line 2

City *required

ZIP / Postal Code

State / Province / Region *required

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