New Patient Demographics and History

Demographics
Patient Name

First NameLast Name
Patient’s sex

Other
Patient’s Date of Birth

MonthDayYear
Date
Patient’s Social Security Number
Patient’s Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact number for patient

Area CodePhone Number
What type of phone is this?
May we leave information at this number?
What kind of information may we leave at this number?

Other
How detailed may the message left at this number be?
How would you like to receive appointment reminders?
Patient Work Number

Area CodePhone Number
Patient’s Email
example@example.com
Employment Status of Patient

Other
Name of Employer
Marital Status of Patient

Other
Language(s) spoken by patient

Other
What category best describes your race (one or more may be marked)

Other
Please specify your ethnicity
Nationality of Patient

Other
Emergency Contact Information
Emergency Contact for patient

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
May we leave information at this number?
What kind of information may we leave at this number?

Other
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How is the emergency contact related to patient?
Other Contact Name

First NameLast Name
Other Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Contact Phone Number

Area CodePhone Number
How is other contact related to the patient?
Pharmacy Information
What pharmacy do you use locally?
Local Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Local Pharmacy Phone Number

Area CodePhone Number
What is your mail order pharmacy?
Primary Insurance Information
Do you have health insurance?
Insurance Company Name (primary)
Subscriber’s Insurance ID number
Group Number
Primary Insurance Effective Date

MonthDayYear
Date
Primary Insurance Subscriber’s Name
Primary Insurance Subscriber’s Date of Birth

MonthDayYear
Date
Primary Insurance Subscriber’s Sex
Patient’s relationship to subscriber of Primary Insurance

Other
Secondary Insurance Information
Secondary Insurance Carrier
Secondary Insurance Subscriber ID number
Secondary Insurance Subscriber’s Name
Secondary Insurance Subscriber’s Date of Birth

MonthDayYear
Date
Secondary Insurance Subscriber’s Sex
Patient’s relationship to subscriber of Secondary Insurance

Other
Any other information you feel we need to know?
Patient Medical History
Have you ever been treated any of the following medical conditions?

Other
Please list any other medical conditions not listed above
Medication Allergies/Adverse Reactions
Surgical History
Current Medications
Primary Care Provider Name

First NameLast NameSuffix
Primary Care Provider Phone Number

Area CodePhone Number
Your other healthcare providers
Psychiatric History
Previous mental health provider
Therapist/Counselor Name

First NameLast Name
Therapist/Counselor Phone Number

Area CodePhone Number
Psychiatric Hospitalizations/Rehab/IOP or PHP
Please list any information on past suicide attempts
Please list information on any history of self harm or mutilation
There is another form available to list past medication trials. If you have tried medications or non-medication interventions like ECT, TMS, etc, please complete that form.
Please provide any additional information you think your provider should know about your psychiatric history. Thank you.
Family History
Parents' History
Siblings' History
Children's History
Other relatives with relevant psychiatric history
Patient Developmental History
Please list any complications with your pregnancy/birth/delivery
Please list any developmental delays and treatments for them that you underwent as a child (OT, PT, speech therapy, etc)
Please list any learning issues and treatments received as a child (include speech therapy, OT, IEP/540, etc)
Did you have any issues making friends or connecting to people when you were young?
Personal History
Where were you born and raised?
With whom did you grow up

Other
Highest level of eduation
Marital Status

Other
Partner's name
Years together
With whom do you live?
Employment

Other
Occupation
Employer
What branch(es)?

Other
How long did you serve?
Legal History

Other
Please list hobbies and interests/community organizations that you enjoy.
Regular Exercise

Other
Pets at home
Have you ever been the victim of violence?

Other
Substance Use History
How many servings of caffeine do you consume in an average day?

Recreational Drug use

Rows	Past Use	Current Use	Rehab
Cannabis/THC
Cocaine/crack
Meth
Stimulants
Ketamine
MDMA (Ecstasy)
Psilocybin (shrooms)
LSD
Huffing
Pain pills/Heroin

Alcohol Use
Alcohol Quantity
Have you ever experienced any of the following due to alcohol use?
Have you required the following treatment due to alcohol use?
Any other information regarding substance use that you feel your provider needs to know?
Is there anything else you feel your provider needs to know? Any specific issues you hope to address at your first appointment?
Should be Empty:

Demographics

Emergency Contact Information

Pharmacy Information

Primary Insurance Information

Secondary Insurance Information

Patient Medical History

Psychiatric History

Family History

Patient Developmental History

Personal History

Substance Use History