Intake For Initial Online Visit

Personal Information

All the information will be stored confidentially with HIPAA-Compliant standard for medical purpose only.

1. Your personal information

First Name:

Middle Initials:

Last Name:

Date of Birth:

Mobile Phone:

Home Phone:

Work Phone:

Street Address:

Apt./Unit #:

City:

State:

Zip Code:

Email:

Preferred contact method:

Mobile Phone Home Phone Work Phone Email

2. Emergency Contact Information

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

3. Will you use your insurance to pay for your medication(if prescribed)? Please be noted that if you choose to use your insurance for medication, Prior Authorization might be required by your carrier which may take them several days to proceed. If you don't want to use your insurance, please talk to your provider and we'll try to help you find a coupon for your med.

Yes No

4. Primary Insurance (only for your medication)

Primary Insurance Company

Member ID/Policy#

Group Number

Plan / Program

Client Relationship to the Insured

Self Spouse Child Other

Insured Name

Insured Phone

Insured Date of Birth

Insured Gender

Male Female

Insured Street Address

Insured City

Insured State

Zip Code

Bin Number

5. Please upload copies of both the FRONT and BACK side of your insurance card (only for your medication)

Files

Add file

Please upload a file

6. Please upload the photocopy of your ID (Passport, Driver's licenses)

Files

Add file

Please upload a file

7. If your provider will prescribe medication for you, please leave the name, address and phone of the pharmacy you will pick it up:

8. Who is your primary care provider? Please include name, address, and phone number if applicable.

Medical Background Information

9. Please list any prescribed medications you take:

Add new row

10. Please list all non-prescription medications, vitamins, and supplements you take:

Add new row

11. Do you currently take any of the following medications?

Medication:

Opiates/Narcotics

Yes No

Mood Stabilizers

Yes No

Suboxone

Yes No

Buprenorphine

Yes No

Subutex

Yes No

12. What's your blood pressure and pulse rate in the past month?

13. Are you allergic to anything? (e.g.: foods, medications, pollens, chemicals, moulds, animal hair, etc.)

14. Have you been diagnosed with any of the following conditions?

If "other(s)", please specify

15. Have you been diagnosed with any of the following mental health disorders?

If yes, please indicate how long

16. Do you suffer from any of the following?

17. you Pregnant or Breastfeeding?

Yes No

18. Any history of mental health conditions including ADHD, Depression, Anxiety or Insomnia, bipolar disorder, psychosis, borderline-personality disorder, manic-depressive illness, or suicide in your family?

19. Are now or have you ever heard voices or seen any visions that are not there?

Yes No

If Yes, Please Explain

Suicide Behaviors Questionnaire

20. Do you currently feel like you want to hurt yourself or others? Have you experienced any symptoms of suicidal ideation?

Yes No

21. Have you every thought about or attempted to kill yourself?

Never I have had a plan at least once to kill myself and really wanted to die It was just a brief passing thought i have attempted to kill myself, but did not want to die I have had a plan at least once to kill myself but did not try to do it I have attempted to kill myself, and really hoped to die

22. Have you had bipolar, psychosis, schizophrenia, suicidal attempts or any mental hospitalization history in the past?

Yes No

If Yes, Please Explain

Your answers on this form may not be seen immediately. If you are having suicidal thoughts NOW, please call the National Suicide Prevention Hotline at 800-273-8255. Please sign below to acknowledge that if you are having suicidal thoughts you need to immediately seek help with NSPH.

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

Signature

Date

Symptomology Questionnaire

23. Are you experiencing any of the following symptoms in the past three months? (Please choose all applied options.)

If checked, please describe

24. What are the major stressors in your life?

25. How long have you had the conditions about which you are consulting us? What are the major stressors in your life?

Less than 6 months More than 5 years 6 months to 2 years 2 to 5 years

26. How long have you had the conditions about which you are consulting us? What are the major stressors in your life?

Stable fluctuating Gradually improving Gradually worsening Rapidly improving Rapidly worsening

27. Please indicate the overall intensity of your symptoms:

Mild very severe Moderate Severe

28. What treatment were you hoping to speak with a practitioner about? Please indicate the overall intensity of your symptoms:

ADHD

Insomnia

Depression

Other

Anxiety

If Other, please describe

DAST 2 Information

We ask for a DAST Screening as part of the intake process.

29. Which recreational drugs have you used in the past year? (Check all that apply)

Recreational Drugs

methamphetimines (speed, crystal)

Cocaine

Cannabis (marijuana, pot)

Narcotics (heroin, oxycodone, methadone, etc)

inhalants (paint thinner, aerosol, glue)

hallucinogens (LSD, mushrooms)

tranquilizers (valium)

None Of The Above

30. How often have you used recreational drugs?

Daily or almost daily On rare occasions Weekly Never Monthly or less

31. In regards to recreational drugs, please answer no or yes to the following statements.

1. Have you used drugs other than those required for medical reasons?

No Yes

2. Do you abuse (use) more than one drug at a time?

No Yes

3. Are you unable to stop using drugs when you want to?

No Yes

4. Have you ever had blackouts or flashbacks as a result of drug use?

No Yes

5. Do you ever feel bad or guilty about your drug use?

No Yes

6. Does your spouse (or parents) ever complain about your involvement with drugs?

No Yes

7. Have you neglected your family because of your use of drugs?

No Yes

8. Have you engaged in illegal activities in order to obtain drugs?

No Yes

9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

No Yes

10. Have you had medical problems as a result of drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?

No Yes

If Yes, please describe

32. Have you ever been in treatment for a drug problem?

Yes No

If yes, please describe

CAGE-AID Questionnaire

33. When thinking about drug use, include illegal drug use and the use of prescription drug other than prescribed.

1. Have you ever felt that you ought to cut down on your drinking or drug use?

Yes No

2. Have people annoyed you by criticizing your drinking or drug use?

Yes No

3. Have you ever felt bad or guilty about your drinking or drug use?

Yes No

4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

Yes No

Patient Health Questionnaire (PHQ-9)

34. Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things

not at all several days more than half the days nearly everyday

2. Feeling down, depressed, or hopeless

not at all several days more than half the days nearly everyday

3. Trouble falling or staying asleep, or sleeping too much

not at all several days more than half the days nearly everyday

4. Feeling tired or having little energy

not at all several days more than half the days nearly everyday

5. Poor appetite or overeating

not at all several days more than half the days nearly everyday

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down

not at all several days more than half the days nearly everyday

7. Trouble concentrating on things, such as reading the newspaper or watching television

not at all several days more than half the days nearly everyday

8. Moving or speaking so slowly that other people could have noticed? Or the opposite?

not at all several days more than half the days nearly everyday

9. Thoughts that you would be better off dead or of hurting yourself in some way?

not at all several days more than half the days nearly everyday

Describe those symptoms here.

General Anxiety Disorder (GAD-7)

35. Over the last 2 weeks how often have you been bothered by the following problems?

1. Feeling nervous, anxious or on edge

Not at all Several days More than half the days Nearly everyday

2. Not being able to stop or control worrying

Not at all Several days More than half the days Nearly everyday

3. Worrying too much about different things.

Not at all Several days More than half the days Nearly everyday

4. Trouble relaxing

Not at all Several days More than half the days Nearly everyday

5. Being so restless that it is hard to sit still.

Not at all Several days More than half the days Nearly everyday

6. Becoming easily annoyed or irritable.

Not at all Several days More than half the days Nearly everyday

7. Feeling afraid as if something awful might happen.

Not at all Several days More than half the days Nearly everyday

Describe those symptoms here.

Adult ADHD Self-Report Scale (ASRS-v1.1)

36. Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today’s appointment

1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?