Insurance Information Birth Date * MM DD YYYY Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Name that appears on insurance card (if different) Policy/Contract Number Group Number Phone Number on back of insurance card (###) ### #### Emergency & Alternative Contact Person(s) Name First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Relationship May we contact this person regarding appointment status only? Yes No May we leave them a message? Yes No General Information Name First Name Last Name Gender Male Female Other Address Address 1 Address 2 City State/Province Zip/Postal Code Country Name of parent or guardian (if applicable) * First Name Last Name Primary Phone (###) ### #### Secondary pPone (###) ### #### May we contact you and leave a message? Yes No Email Marital Status Never married Domestic partnership Married Separated Divorced Widowed Please list any children and their ages Are you currently employed? Yes No Please describe your employment, if applicable Title of occupation Name of employer/company How long have you been with this place of employment? Do you consider yourself to be spiritual or religious? Yes No Please describe your faith or belief Referred by (if any) First Name Last Name General Health and Mental Health Information Have you ever received counseling services before? Yes No Please list dates or approximate times/duration of treatment and with whom Are you or have you ever been involved in AA, NA, or another 12-step program? Yes No Which group? When and how often and for how long have you been involved with this group? Have you ever been hospitalized for behavioral, emotional, or substance abuse services? Yes No Please provide approximate dates and location Are you currently taking any prescription medication for anxiety, depression, panic attacks, or insomnia? Yes No Please list medication name, duration, dosage, and prescribed physician List all other medications you're currently taking (i.e., blood pressure, thyroid, diabetes, etc.) along with prescribed physician Are you experiencing any of the following symptoms? Depressed mood Crying spells Decrease in activity Decrease in self care Sleeping too much/too little Lack of energy/motivation Eating too much/too little Excessive worry Anxiety attacks Anger problems Irritability Increased alcohol use Obsessive thinking Phobias Low self-esteem Isolating from others Frequent nightmares Overly dependent In general, how often to these symptoms occur, and how long have you been experiencing them? Do you have a history of physical, emotional, or sexual abuse? Yes No Please briefly explain Are you currently experiencing any chronic pain? Yes No Please describe How much alcohol do you consume in a week? How much/what kind of recreational drugs do you use? Additional Information What is your perception of the problem/situation for seeking therapy? What are you wiling to do about this present situation/problem? What are your top 3 goals for therapy? Digital Signature Please type your name within the statement below. This serves as your digital signature in agreement with the information provided within this information. Name I, to the best of my ability, have been truthful with the above mentioned information, and if further information is needed, I agree to provide to this agency. First Name Last Name Date MM DD YYYY Telemental Health Informed Consent Please complete this section in the event of any and all Mental Telehealth sessions, planned or otherwise. Thank you!
