Intake Form

What is your preferred appointment type

Telehealth

In-Person

No preference

If your preferred provider does not have availability, are you willing to see a different provider?

Yes No N/A

(if answered "No Preference" to the previous question)

Patient Legal First Name

Patient Preferred Name

Patient Last Name

Phone Number

Is the phone number provided the patient's personal phone number?

Yes No

Email Address

Patient SSN

Your SSN is REQUIRED for you to be seen for ANY appointment. You will NOT be contacted if this section is not filled out properly. Your SSN is REQUIRED to properly identify you.

Date of Birth

Gender Identity

Preferred pronouns

Address in which patient currently resides

City and state in which patient currently resides

Zip Code

Insurance Company

Washington State Medicaid?

Yes No

ProviderOne Card Photo Front

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ProviderOne Card Photo Back

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Insurance ID Number

Insurance Group Number

If not applicable, put N/A

Are you the insurance subscriber?

Yes No

Insurance subscriber's first name

Insurance subscriber's last name

Insurance Subscriber Date of Birth

Insurance subscribers SSN

Photo of front of insurance card (JPEG or .jpg files only)

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Photo of back of insurance card (JPEG or .jpg files only)

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Photo of Front of Driver's License or ID

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Photo of Back of Driver's License or ID

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I understand that New Dawn Psychiatric Care is offering video as well as in person appointments.

Video appointments are also known as Synchronous Telemedicine. When you call your insurance company to check on your mental health benefits, you should specifically ask about these benefits, and check that the provider(s) you are interested in seeing will be covered.

Patients are responsible for knowing their mental health benefits.

While our providers are in-network with most plans administered by the above companies, there are unique plans that may not include our providers within their network, or the mental health benefits are through another company. (Ex: Premera from Swedish Hospital / Providence is OON for mental health.)

I understand that my potential nurse practitioner's primary role is prescribing and managing medication. While my nurse practitioner may incorporate some psychotherapy interventions (talk therapy) into my medication management appointments, this is not meant to be a substitute for individual psychotherapy with a licensed therapist.

What are the issues, concerns, etc. that you would like to receive services for?

Please be as specific as possible. (Example: Depression, Anxiety, etc.)

Please list ALL the medications are you currently taking: including prescription medications, over the counter medications, vitamins, and supplements. Please make sure to list medication name, dosage, and how often you take the medication.

Please list all psychiatric medications taken in the past.

What is your current prescribing provider's name?

What is your current talk therapist / counselor's name?

Have you ever been hospitalized for psychiatric purposes?

If "yes," please elaborate (date of hospitalization, reason, voluntary vs. involuntary, etc).

Do you have history of substance use concerns? (ex: drugs, alcohol, food)

If "yes," please elaborate.

Have you ever self-harmed?

Have you ever attempted suicide?

If "yes," please specify when this occurred.

Do you currently have suicidal thoughts?

If "yes," please elaborate.

Are there any legal issues you are dealing with? (Ex: divorce, restraining order, lawsuit, etc.)

If "yes," please elaborate.

Do you have any history of violent actions? (Ex: Throwing things, punching walls, road rage, physical fights, etc.)

If "yes," please elaborate (specific violent action, frequency, etc.)

How did you hear about us? Please let us know so we may thank them!

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Provider name

Please elaborate

Name of person completing this form, and relation to patient:

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relation

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