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

Please correct the errors described below.

Demographic Information

Please provide legal first and last name

Secondary address or phone numbers used

Please list all persons with whom you are currently living

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Employment History

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

Please list your past employment for the past ten years.

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Educational History

Legal History

If yes please list charges below.

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Marital/Relationship History

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

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Childhood History

Please list all parental figures in your life

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Please list your siblings

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

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Military History

Substance Abuse History

Medical History

Other Information

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:

Insurance Policy Holder Information

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

Please attach front and back copy of insurance card.

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