INTAKE QUESTIONNAIRE

Pre-Visit Intake

Date:

Person Completing Form:

Relationship

Patient LName:

Patient FName:

Middle Init:

Date of Birth:

Age:

How do you want to be address:

Patient phone #'s:

Address (Street, Apt, City, State, Zip)

Cell

Email:

Emergency Contact Name

Relation:

Email:

Phone #:

Patient Employer:

Spouse/Partner Name:

Referral Name & Phone #

The reason you are seeking care (description, problems, symptoms, etc)

Family Physician:

Phone #:

Therapist Name:

Phone #:

Primary Insurance & Phone #:

Subscribers Name:

Relation:

Subscriber DOB:

Subscribers Employer:

Member ID#:

Medicaid Coverage:

Group#Other:

Disclaimer: Providers are not accepting new Medicaid Primary or Secondary insurance and they are NON-Participating with Medicaid HMO's. Visits and Medication will not be covered and referral to insurance will be made for in-network providers.

Secondary Insurance

Our practice will coordinate care with your current therapist. However, you are not required to be in therapy. The providers of AIP will complete psychiatric evaluation, diagnosis, and psychopharmacology treatment plan. If you agree to treatment plan you will continue with medication management. Individual Psychotherapy also known as "Talk-Therapy", is not provided. Please provide a list of in-network therapist that participate with your insurance and the psychiatrist will try to make recommendation.

OUR DOCTORS DO NOT PROVIDE THERAPY or complete paperwork for work comp/auto/disability

Urgency estimates:

DISCLAIMER: IF YOU ARE CONSIDERING OR CONTEMPLATING SUICIDE OR FEEL THAT YOU MAY BE A DANGER TO YOURSELF OR OTHERS, PLEASE NOTIFY THE POLICE (OR) CONTACT EMERGENCY MEDICAL SERVICES (911) IMMEDIATELY.

Suicidality/Homicidality: Are you currently having thoughts of harming yourself or others:

Yes No

If yes to suicidal thoughts, do you have a plan:

If yes to suicidal plans, do you have intent:

If yes to homicidal thoughts, do you have a plan:

If yes to suicidal plans, do you have intent:

Admit Denies

Our practice provides outpatient psychiatric services, and is not equipped for emergency services. Please be advised if you experience an escalation in symptoms, resources are available. Patients with plan and/or intent of harm to self or others should go to the nearest hospital emergency room. If you are in crisis or mental health distress dial or text 988 for the National Suicide and Crisis Lifeline. Dialing 911 is also available for life threatening emergencies.

Is the evaluation required for an auto or work disability claim?

Yes No

Auto?

Yes No

Work?

Yes No

Is the evaluation required for on any type of Medical Leave of Absence?

Yes No

Reason:

Is the evaluation required for legal proceedings?

Yes No

Civil:

Yes No

Criminal:

Yes No

Other:

Ok, now I need to ask about Substance Use:

Are you currently using medical marijuana?

Yes No

Do you have State of MI Marijuana Card?

Yes No

Frequency:

Type:

Are you currently using recreational marijuana?

Yes No

Frequency:

Type:

Any Use of Alcohol?

Yes No

Frequency:

Quantity:

Any Use of Tobacco?

Yes No

Frequency:

Quantity:

Are you Abusing OTHER Substances?

Yes No

Substances:

Last Used:

Allergies:

Yes No

Allergy Comments:

COVID: Other:

Current Medications, dose, strength: (list name, dose, and frequency)

Add new row

What is your preferred local Pharmacy Name & Phone#?

Do you consent to have your prescription history pulled electronically?

Yes No

Who the Current Prescriber?

Phone #

Have you had a recent Medical Hospitalization?

Yes No

If yes, reason:

Hospital Name:

Hospital Discharge Date:

Have you had past Psychiatric Hospitalization(s)?

Yes No

Quantity:

Last Discharge Date:

Psychiatric Hospital Name:

Questions/Comments/Notes/Accommodation Request:

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