Eclipse Mental Health Services

Patient Name:

DOB:

Biological Sex Orientation

Gender Identity

Identifying Pronouns

Address:

Zip:

City:

SSN:

Phone

Email

Emergency Contact:

Date:

Why are you seeking treatment with Dr.Hayes?

What is your primary insurance?

Do you have ANY other insurance?

Please list current diagnosis and recent provider that made the diagnosis.

If Other, please specify:

How long have you suffered from depression?

Have you ever had a manic episode?

Y N

How long have you suffered from anxiety?

Do you worry about this occurring again?

Y N