Information Form for Visit with Nathaniel Smith, LCSW-R

Nathaniel Smith, LCSW-R

351 Manville Road, Suite 101, Pleasantville, NY 10570

Telephone: (917) 538-3532
Email: nsmithlcsw@nym.hush.com
NPI # 199-271-8415

Information Form

I have read the below statement

Those not using in-network insurance do not need to complete this form. This form is for my insurance record keeping requirements only. You may be brief as we will go over all relevant information directly during our meeting. Nathaniel Smith can not hold video sessions with people who are outside of NY State at the time of the meeting and can't accept Medicaid related (Including any plans with ID numbers beginning with JLJ) or SWSCHP administered plans.

First name:

I have uploaded my address and insurance ID number to Zocdoc.

I am in agreement with the telehealth notice available separate from this form.(If applicable)

Yes No N/A: Not applicable to me, I am meeting in person at the office.

I understand the terms of the HIPAA privacy agreement available separate from this form.

Yes No

Please describe the current concerns/symptoms:

For approximately how long have the above occurred?

Please describe your goal(s) in seeking help at this time:

Have you ever been hospitalized for a psychiatric issue?

Yes No

If applicable please describe reason and approximate dates for any past psychiatric hospitalizations:

Are you currently being prescribed psychiatric medication?

Yes No

Name of practitioner currently prescribing psychiatric medication:

Town or city in which current prescribing practitioner practices:

Any past use of psychiatric medication?

Yes No

To the best of your memory, please list any past psychiatric medications. and approximate dates of use:

Have you attended psychotherapy sessions in the past?

Yes No

If applicable please describe reason and approximate dates for any past psychotherapy:

For how long and with whom do you currently live?

Please describe any current employment, school, family or other responsibiilites:

Is there any concern/important history related to alcohol/drug use?

Yes No

If applicable please describe any current/past alcohol/drug use of significance:

Any current or past thoughts about or actual dangerous behavior towards yourself or others?

Yes No

If applicable please describe any current or past thoughts about or actual dangerous behavior towards yourself or others?

Any current or past physical, sexual or emotional abuse?

Yes No

If applicable please generally describe any current or past physical, sexual or emotional abuse:

Any significant current/past health issues?

Yes No

If applicable please describe any significant current/past physical health issues?

Any significant past history of loss or trauma?

Yes No

If applicable please describe any history of loss or trauma:

Please describe any further information that you believe is important:

Thank you for your assistance in completing this form. Please provide any feedback or concerns about this form to Nathaniel Smith, LCSW-R. When you are finished, please click the submit button below.

Online form submission is encrypted and HIPAA approved. Form below only asks for last initial to further safeguard privacy.

Please contact me if you have any questions about the HIPAA privacy agreement or telehealth agreement (attached to an email sent to you) or anything related to this form or our meeting. Thank you!

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