Better Days and Nights PLLC Secure Client Intake Form
Please fill out all the questions you can. Some boxes/questions are required and have and asterisk next to them. If you can not answer a required question please fill it with XXXXX's or 00000's. Thank you
Email or text correspondence is not considered to be a confidential medium of communication.
The following questions refer to the person that actually is the primary beneficiary of the policy. It could be you, your spouse, or parent.
Assignment of insurance benefits:
I hereby authorize direct payment of Mental Health benefits to the Therapist or to whomever he/she designates, and I also authorize direct payment of all other benefits to Better Days and Nights and its subsidiaries. The benefits referred to herein would be payable to me if I did not make assignment and include major medical insurance. I understand to my satisfaction that I am personally responsible to the Practice and Therapist respectively for charges not covered by this agreement. I agree to pay out-of-pocket for sessions lasting more than 60 minutes at the rate of $100.00 per hour broken down in to 15-minute segments of $25.00. I also authorize Better Days and Nights and my attending Therapist to release any medical information required in processing of applications for final insurance coverage for services rendered.
Mental Health Status:
General Health Information:
FAMILY MENTAL HEALTH HISTORY:
In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s (father, grandmother, uncle, etc.) next to each.
Signing below you agree that your Better Days and Nights therapist and or office employees can contact you or your Emergency Contact via phone, email or text as check above.
Instructions: The questions below ask about things that might have bothered you. For each question, choose numbers 0 - 4 that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.
Item 0 None at all
Item 1 Slight or Rare, Less than one day or two
Item 2 Mild Several Days
Item 3 Moderate more than half the days
Item 4 Severe nearly every day
1. Little interest or pleasure in doing things?
2. Feeling down, depressed, or hopeless?
3. Feeling more irritated, grouchy, or angry than usual?
4. Sleeping less than usual, but still have a lot of energy?
5. Starting lots more projects than usual or doing more risky things than usual?
6. Feeling nervous, anxious, frightened, worried, or on edge?
10. Feeling that your illnesses are not being taken seriously enough?
11. Thoughts of actually hurting yourself?
12. Hearing things other people couldn't hear, such as voices even when no one was around?
13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
14. Problems with sleep that affected your sleep quality over all?
15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?
16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?
17. Feeling driven to perform certain behaviors or mental acts over and over again?
18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
19. Not knowing who you really are or what you want out of life?
20. Not feeling close to other people or enjoying your relationships with them?
21. Drinking at least 4 drinks of any kind of alcohol in a single day?
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
23. Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)?
Thank you for your time, please click send below.
Your information will be encrypted.
Better Days and Nights PLLC
Your browser does not support capabilities required for electronic signatures.