Lakeview Medical and Psychiatric Healthcare Adult Form

Dear Future Client, we wanted to extend our heartfelt gratitude to you for taking the time to complete our new intake form. Your willingness to share essential information about your health and needs is invaluable and greatly appreciated. Your thoroughness in providing us with this information will enable us to better understand your unique circumstances and tailor our services to meet your specific needs. Your commitment to your own well-being is a testament to your proactive approach to healthcare, and it is a pleasure to have you as a patient. Please know that your trust in our practice is not taken for granted, and we are here to support you every step of the way. If you have any questions or need further assistance, please don't hesitate to reach out. Your health and comfort are our top priorities. Once again, thank you for your time and cooperation. We look forward to working with you to provide the best possible care and support for your mental health. Warm regards, Lakeview Crew

Prior to completing form please confirm our providers are in your insurance network with your insurance company. If not we do offer a self pay option.

This form helps us learn about your medical and psychiatric history. Please complete it to the best of your ability. Not every question is relevant to everyone. If you feel uncomfortable answering a question, leave it blank.

309-575-3222
macomblakeview@hush.com

Demographic Information

Name

Please provide legal first and last name

Social Security #

Age

Date of Birth

Secondary address or phone numbers used

May we leave a voicemail and/or send secure message?

Yes No

Please list all persons with whom you are currently living

Click to add more

Name any children to whom you are a parent figure

Employment History

Are you currently employed?

Yes No

If currently employed please provide use with the name of employer, position, and length of employment.

Name of Employer

Position

Date of Hire

Please list your past employment for the past ten years.

Click to add other employment history

Please describe any current or past work related probems (e.g. harrassment, conflicts).

Educational History

What is the last grade you completed?

Do you have a history of special education?

Yes No

If Yes, what grades?

Have you ever been held back a grade?

Yes No

If Yes, what grade?

Have you attended any college?

Yes No

If yes, where and what degree was obtained?

Other training or certifications obtained?

Do you plan on furthering education? If yes please describe below

Do you have any learning difficulties? If yes please describe below.

Legal History

Have you ever been arrested?

Yes No

If yes please list charges below.

Are you currently on probation or parole?

Yes No

If currently on probation or parole please explain conditions.

Have you ever filed a lawsuit against anyone or had a lawsuit filed against you?

Yes No

If yes, please describe below.

Marital/Relationship History

List all significant relationships (marriage,cohabitation,long term boy/girlfriends)

Click to add more

Have you ever been the victim or perpetrator of spouse abuse?

Yes No

If yes, please describe below.

Childhood History

Location of birthplace?

Did you have any developmental delays?

Yes No

If yes, please describe below.

Please list all parental figures in your life

Click to add more

Please list your siblings

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Were there problems with your birth or prior to your birth?

Yes No

If yes, please describe below.

Please list all significant events in your family (divorce, separation, death serious illness, etc.)

Click to add more

Describe your experience growing up.

What was your mother like? How did she treat you?

What was your father like? How did he treat you?

What were your siblings like? How did they treat you?

What were your experiences like with friends?

Describe the most positive relationships in your life you had growing up.

Where you every physically, sexually, or mentally abused?

Yes No

If yes, please describe.

Describe any other traumas, tragedies, or difficult circumstances you experienced.

Military History

Were you in the military or currently in military?

Yes No

If yes, please describe the dates of service, branch, and discharge status.

Substance Abuse History

Do you currently drink alcohol?

Yes No

Have you ever drank alcohol?

Yes No

If yes, age at first drink.

Date of last drink (if applicable)

How many drinks containing alcohol do you have on a typical day when you are drinking?

How often do you have a drink containing alcohol?

Do you currently smoke, chew, or use any nicotine/tobacco products?

Yes No

Do you currently smoke/inhale/ingest marijuana products?

Yes No

If yes, age at first use.

Date of last use.

How much?

How often?

Do you currently use illicit or non-prescribed drugs?

Yes No

Do you have a history of using illicit or non-prescribed drugs?

Yes No

If yes, age at first use.

Date of last use.

What drugs?

How often?

How much?

Have you ever attended substance abuse counseling?

Yes No

If yes, for how long?

Medical History

Do you currently have a medical illness?

Yes No

List any other important medical condition(s) and or Surgeries you have had (do not include common colds or flu). Include date or age of initial diagnosis/surgery if possible:

Are you currently taking any medications, supplements or herbal remedies?

Yes No

If yes, please list all current medications and/or supplements, herbal remedies taking.

Have you ever attended counseling for mental health concerns?

Yes No

If yes, when and for how long?

Please list your current Psychiatrists, Psychologist, and Counselors

Have you ever been hospitalized on a psychiatric unit?

Yes No

If yes, when and for how long?

Have you ever experienced a head injury?

Yes No

If yes, when and did you lose consciousness?

Do you have any allergies?

Yes No

If yes, please list below.

Other Information

Please list any other information that you see as important.

By signing below, I hereby acknowledge all information provided above is true to the best of my knowledge.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

This was signed by:

Name

Date

Relationship to patient (if other than patient):

I am currently interested in these services:

Medication Management

Therapy

Medication Management and Therapy

Insurance Policy Holder Information

Carrier

e.g. Health Alliance, Blue Cross Blue Shield, Health Link, Aetna

Policy Holder Name

Policy Holder Phone Number

Policy Holder Date of Birth

Policy Holder Address

City

State

Zip Code

Policy Holder Social Security No.

Relation to Policy Holder

Please attach front and back copy of insurance card.

Insurance Card

Add file

Please upload a file

Secondary Insurance

Add file

Please upload a file

Your information will be encrypted.

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