"*" indicates required fields Patient Name* First Middle Last Patient Date of Birth* Month Day Year Patient Age*Patient Sex*Marital Status*Patient Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Secondary PhoneResponsible Party*Relation to Patient*Patient or Parent E-mail Address* Insurance Carrier*Type of Insurance* PPO/HMO QUEST/MEDICAID Insurance Subscriber Name*Insurance Member ID*Insurance Subscriber Address(Leave blank if same as patient) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Subscriber Date of Birth* Month Day Year Subscriber Sex*Referred By*Primary Care Doctor*Do you have a prior or current Psychiatrist/Therapist/School Counsellor?* Yes No Name of prior or current Psychiatrist/Therapist/School Counsellor*Last appointment attended* MM slash DD slash YYYY How long with this prior provider?*Current Medications?School/Grade/Employment StatusSchoolGradeEmploymentHow many people reside in the home with you/patient?* 1-3 4-6 None What is their relation to you/patient? (list relation, sex, and age)RelationRelationRelationAgeAgeAgeSex Male Female Sex Male Female Sex Male Female RelationRelationRelationAgeAgeAgeSex Male Female Sex Male Female Sex Male Female Main Concerns (how long occurring?)* Δ
