New Patient Health History (Adult)

Emergency Assistance

If this is an emergency, call:

Crisis Line: (800) 273-TALK
911

How did you hear about our office?

Specific services which you are seeking from our office

If there is a specific provider you wish to see for your services in our clinic please provide their name.

Patient Demographics

First name

Middle Name or Initial

Last name

Date of Birth

Home Address

Zip Code

Contact Phone Number

Social Security Number

Email address

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Yes

Emergency Contact Information

Full Name

Cell phone number

Do you have a guardian?

YES

If YES, include name(s) and contact phone numbers below

Insurance Company and Policy Number

Enter "none" if no answer is applicable, thank you!

Secondary Insurance and Policy Number

Enter "none" if no answer is applicable, thank you!

Check Yes below if you are applying for the LCA membership services plan and do NOT have medical insurance.

YES, I am applying for membership

NO, I have medical insurance

Health History (Adult)

Briefly describe the event(s) over the past several weeks that have prompted a request for psychiatric evaluation at this time:

Names of CURRENT PSYCHIATRIC medications you are currently NOW taking:

Names of ALL OTHER medications, herbs or over-the-counter agents you are NOW taking:

Past Psychiatric History

Age when ANY mental health symptoms first began:

Symptoms experienced when mental health concerns first began:

Eg. Sadness, anxiety, insomnia, etc

Mental health or medical professionals seen, now or in the past, for evaluation and/or treatment of mental health concerns:

Period of time (during lifetime) when functioning the best:

Past psychiatric hospitalizations (names and locations):

Number of prior suicide attempts and nature of attempt(s):

Substance Abuse

Age of first use of alcohol or any recreational drugs:

Substances used more than once:

None

Alcohol

Marijuana

Methamphetamine

Cocaine

Heroin or Opioids

Ecstasy

Hallucinogens (eg. LSD, Acid, Shrooms, Psilocybin, Ecstasy) )

Inhalants

Use of other substances including prescription pain, stimulant or sedatives that have been abused in the past:

Last use of alcohol, illicit or recreational substances:

Past or present legal, personal, vocational difficulties associated with alcohol, drug use and preferred substance of abuse:

Tobacco Status

Never smoker Former smoker Everyday smoker Light smoker

Medical History

Allergies to medications

Name of current pharmacy

Family History

Other mental health or substance use disorder history among your relatives

Family members with a diagnosed mental health or substance use disorder:

mother

father

sibling(s)

grandparent(s)

aunt or uncle or cousin

Social History

City and State where you were born and raised:

Description of temperament and behavior as a CHILD:

(Eg. hyperactive, moody, happy, anxious, temperamental, etc.)

Number of siblings and birth order:

Perception, as a child, of how parents thought of and treated you:

(Eg. loved, ignored, blamed, smart, etc)

Traumatic or abusive events include:

Sexual

Physical

Emotional

No history of sexual, physical or emotional abuse

Description of father's or step-father's personality and relationship to him/them:

Description of mother's or step-mother's personality and relationship to her/them:

Family structure described as:

(Eg. too strict, harsh, difficult, affectionate, close, unstable, too loose, etc)

Performance during GRADE school:

Performance during HIGH school:

Highest level of education:

Did not graduate from High School

High School Diploma

GED

Associates Degree

Bachelors Degree

Masters Degree or other postgraduate degree

Current employment status, longest period of employment:

Financial problems attributed to mental health problems:

Support system and/or your most important relationships at this time:

(Eg. mother, spouse, friend, partner, etc)

Impairments with housing, grooming, meal preparation, work or school performance, cleaning and self care, coping skills and problem solving that are related to a mental health disorder:

Military history, rank at discharge, disciplinary actions, etc:

Prior arrests, time in jail, prison or current legal problems:

Religious or spiritual practices:

Marital history:

married

never married/single

divorced

separated

divorced and remarried more than once

Number of children and ages:

Hobbies and interests:

Personal strengths:

Mental health symptoms have impaired functioning in the follow areas:

school or work performance

management of finances

ability to communicate, cope, problem solve and resolve conflict

healthy leisure, recreation and social activities

personal relationships in the settings of family, work, school, church or community

Examples of impaired functioning as noted in question above:

Thank you! We will contact you soon to schedule your appointment.

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Life Change Associates

Our Mission Statement and Treatment Philosophy Life Change Associates offers expert diagnostic services, follows best practice recommendations, and guidelines in an atmosphere of mutual trust and respect. Rational and thoughtful application of approved treatments are employed in order to enhance physical, emotional, spiritual and social growth. Our approach to wellness and recovery includes both brain and mind targeted treatments. A return to wellness and the promotion of full recovery for each patient is the goal of Life Change Associates.

+1-208-233-5433
lifechangeassociates