I verify that I have contacted my insurance company to ask if my mental health benefits cover Karen Casseday and asked if I need a pre-authorization or referral from my primary care provider. I understand that I am ultimately responsible for any charges for services rendered with KC Family Hope Center.*
Yes No
Intake Paperwork
Patients may have other forms to fill out upon arriving at the appointment
Patient's Full Name*
Preferred Name/Nickname
Birth Date*
Month Day Year
Is Patient a minor*
Yes No
Gender*
School & Grade
Average Grades
Patient's Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Patient's Cell #*
Patient's Home #
Patient's E-mail
Communications OK to leave a message on:*
Home Phone Email Text Cell Phone None
Parent's Name
Parent's #
Parent's Name
Parent's #
Is there a parenting/custody agreement? If so, please bring a copy with you
Yes No
Emergency Contact*
Emergency Contact Number*
Therapist Name
Therapist Number
Primary Care Provider's Name*
Primary Care Provider Number*
Did Patient's Primary Care Provider refer to our office?*
Yes No
If Primary Care Provider did not refer patient who may we thank?
Financial Information
We highly recommend calling the patient's insurance to verify their mental health benefits cover Karen Casseday and ask if the patient will need a pre-authorization or referral from the primary care doctor.
Patients are ultimately responsible for charges related to their account and services rendered.
There is a deposit for patients without insurance. A $250 deposit is required at the initial evaluation check-in towards the evaluation charges. If there is a remaining balance after there will be a statement sent to the responsible party. Feel free to have the responsible party contact the insurance (if Karen Casseday is out of network) and ask about out of network benefits as well as guidelines for possible reimbursement. The office manager can be of assistance to help in this process. Payment arrangements can be discussed by calling the office manager at 360-567-6109.
How does patient plan to cover services?:*
Self Pay Behavior Health Insurance covers Karen Casseday
Does your insurance require a referral or pre-authorization from primary care provider?*
Yes No
Responsible Party
Relation
Responsible Party Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone #
Primary Insurance
Behavioral Health Coverage
Policy #
Group #
CoPay
Subscriber's Name
Subscriber's D.O.B
Subscriber's Phone #
Relation to Patient
Secondary Insurance
Behavioral Health Coverage
Policy #
Group #
CoPay
Subscriber's Name
Subscriber's D.O.B
Subscriber's Phone #
Relation to Patient
Policies & Procedures
***Some procedures/charges may not be paid by your insurance company. ***
Please be advised of the following charges, but are not limited to
Electronic Communications: $20.00 to $60.00
Phone Calls:     $20.00 to $60.00
Initial Evaluations:   $345.00 to $520.00
Follow Up Appointments:   $135.00 to $405.00
Requests for paperwork/documents outside of appointments will have a $25.00 minimum
Late Cancellation & No-Show Policy
Please be advised that your appointment is set for a scheduled amount of time. If you are more than 10 minutes late you may reschedule but will be charged for the late cancellation charge. If you are late for your appointment and do not wish to reschedule, you will be seen for the amount of time left during that scheduled time.
• 1st Late Cancellation & No Show is given as a freebie.
Thereafter each one is subject to a full appointment charge.
Insured Assignment and Release of Information
I hereby authorize my insurance benefits to be paid directly to the provider. I realize that I am responsible to pay for any non-covered services and that I will be liable for a monthly finance charge of 1.0% or $5.00, whichever is greater, on balances over 60 days past due. I understand that I am also responsible to pay a late cancellation or no-show charge for failure to arrive at my appointment at the scheduled time or failure to provide 24 hours advance notice for canceled appointments. If not paid according to terms I understand that my account may be turned over to a collection agency, in which case I agree to pay all additional fees assessed in a collection of the debt. These fees include collection agency fees and attorney fees. I understand that there will be a $25.00 charge assessed on all returned checks.
I hereby authorize the release of pertinent medical information to the insurance company if necessary, to assist in claims processing as requested by the insurance company.
Legal Services
Please be advised I do not provide psychiatric evaluations that are court mandated or
for use of court cases such as child custody cases. If I am subpoenaed and must appear
in court or communicate with members of a legal team, I will bill an hourly rate and fees
accordingly if this interrupts my ability to care for other patients during that time.
Agreement between Divorced/Separated Parents
KC Family Hope Center’s policy regarding families who are in the process of parent separation/divorce, are separated/divorced or who are dealing with conflicts regarding co-parenting issues are stated below. If both parents understand and agree to this policy, it will allow me to serve you and your child most effectively and will minimize conflicts between parents regarding services. KC Family Hope Center prefers input from both parents. This may involve scheduling parent appointments to discuss communication and collaboration, in addition to child appointments. Both parents are very important in the lives of their children and children generally do best when they have active, healthy relationships with both parents. Children generally do best when parents treat each other with respect and cooperate with each other. Children suffer when there is ongoing, unresolved conflict between their parents. The success, or failure, of counseling children, often depends heavily on the support by both parents. I do not do assessments to assist parents, attorneys or the court in making decisions regarding Parenting Plans.
We (parents) fully understand and freely agree to these conditions regarding services for our child or children, and for ourselves regarding KC Family Hope Center.
Electronic Communication Policy & Informed Consent

Electronic communications include but is not confined to email, text
messaging, and instant messaging. By signing below, I ,(CLIENT) understand that: Electronic communications are inherently insecure, and should CLIENT choose to communicate withproviderin this way CLIENT does soknowingits limitations in security and confidentiality. CLIENT understands Provider will take reasonable, appropriate and necessary precautions to keep electronic communications secure; however, in the event of a security breech CLIENT is aware that Provider cannot guaranteesecurityof data.
•Providerwill take all reasonable precautions to maintain the confidentiality and security of electronic messages. CLIENT understands also that it is their responsibility to ensure the security of messages being stored within CLIENT’s own email, text, IM, SMS, etc. accounts, on CLIENT’s own computers and/or phones and their records.
• CLIENT must initiate electronic communication first to ensure thatProviderhas the correct address. This message must includeCLIENT’sfull name in the body of the message.
• Technical difficulties (power outages, lack of internet access, etc.) may occur which might preventmessagebeing received, read, or replied to by Provider, sent by Provider, and/or received by CLIENT. In suchcasesCLIENT is responsible for following up with Provider by phone if a message is not acknowledged within 48 hours.
• Electronic communication is NOT for emergencies or notification of cancelations. CLIENTunderstandthat the best way to notify Provider ofa cancelationis to leave a voice mail.
• Sensitive issues and information should not be addressed in electronic communication but saved for individual appointments.
• CLIENT should use a non-work-based email account &/or cell phone account due to confidentiality and the potential monitoring an employer might utilize for their email servers and/or employee communications
• Any email necessitating a long reply (greater than 8 lines) may incur a fee to be added toCLIENT’saccount for the time spent reading and replying to the message.
• All emails and replies will be printed forCLIENT’sfile or kept with CLIENT’s electronic records. Text messages will be summarized as communication inCLIENT’sfile.
• No electronic communication will be forwarded to anyone without a signed release on file specifically authorizing disclosure to that individual unless they are the CLIENT or the legal guardian of a client who is under the age of 13 years.

PATIENT TREATMENT CONTRACT

As a patient of Karen Casseday, ARNP, I freely and voluntarily agree to accept this treatment
contract as follows:
I agree to take responsibility for my treatment. I will schedule and keep appointments within the agreed upon time frame.
I understand that the need to cancel an appointment, once scheduled, should be the exception and not the rule.
I agree to arrive on time and prepared for my appointment. This means I will come prepared to pay any co-pay I may have.
I will advise the office of any medication changes I have had since my initial visit, and I will be prepared to list all of my medications, including dosing instructions.
I will write out and bring a list of any questions or concerns that I may have, including, but not limited to, potential side effects that I have experienced since my last follow-up appointment with the provider.
I agree to come in sooner than my previously scheduled follow-up appointment if my provider feels it necessary.
I agree to take all medication as prescribed and to notify my provider with any questions and/or concerns I may have before decreasing/increasing, stopping, or altering medications prescribed by my provider.
I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of the law and of this agreement and would result in my treatment being terminated without any recourse for appeal.
I agree that some of my prescriptions can only be given to me at my regular office visits and that a missed visit may result in my not being able to get my prescription until I talk with my provider. I understand that I must allow two business days to process refill requests.
I agree and understand that my provider will not renew any of my medications if it has been 6 months or more since my last follow up appointment.
I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place. I understand and agree that my provider will not replace prescriptions for controlled substances regardless of why it was lost, stolen or damaged.
I agree to be completely truthful and honest with my provider.
I understand that medication alone may not be sufficient treatment for my condition. Therefore, I agree to participate in counseling as discussed and agreed upon with my provider.
I agree to get lab work done as ordered by my provider and to do so within the requested time frame.
I understand that I may conclude services with my provider at any time for any reason. However, I will remain fiscally responsible for any unpaid balance from the services already provided.
I understand that violation of any part of this treatment contract gives my provider the option of immediately concluding treatment services with me.
My signature indicates that I have read or been read, understand, and agree to the terms listed within this treatment contract. I also understand that patients under the age of 18 years must also have their parent or legal guardian sign this treatment agreement and that their signature implies responsibility in overseeing and supervising the underage patient to assure compliance to this treatment agreement.
Notice of Privacy Practices

This notice describes how medical information about you may be used, disclosed, and how you can get access to this information. *Please carefully review and retain for your records.

Understanding Your Health Record Information
Each time you visit or contact your mental health care provider, a record of this contract is made. This information often referred to as your “chart”, serves the following purposes: 1) a basis for planning your care and treatment, 2) a means of communication among the many health and mental health professionals who contribute to your care, 3) a legal document describing the care you received, 4) a means by which you or a third-party payer can verify that services billed were actually provided, 5) a source of data for education, research, and planning, 6) a source of information for public health officials charged with improving the health of the nation, and 7) a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve. Understanding what is in your record (chart) and how your mental health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access this information, and helps you to make more informed decisions when authorizing disclosure to others.
Your Health Information Rights

Although your mental health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right t:: 1) obtain a paper copy of the notice of privacy practices upon request, 2) request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522 (a), however, we are not required to agree to such a restriction, 3) receive confidential communications of your protected health information per 45 CFR164.522 (b), 4) inspect and copy your mental health record as provided for in 45 CFR 164.524, 5) amend your record as provided in 45 CFR 164.526, 6) receive an accounting of disclosures of your mental health information as provided in 45 CFR 164.528, 7) request communications of information by alternative means or at alternative locations, 8) revoke your authorization to use or disclose mental health information except to the extent that action has already been taken.
My Responsibilities
Karen S. Casseday, ARNP is required to: 1) maintain the privacy of your mental health information, 2) provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you, 3) abide by the terms of this notice, 4) notify you if we are unable to agree to a requested restriction, 5) accommodate reasonable requests you may have to communicate information by alternative means or at alternative locations. We will not use or disclose your information without your authorization, except as described in this notice. We reserve the right to change our practices and to make any new provisions effective for all protected health information we maintain. Should our information practices change, we will post the revision in our lobby and upon request mail a revised notice to the address you’ve supplied to us. Correctional Institutions: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof, mental health information necessary for your continuity of care and the safety of you or other individuals. Furthermore, information may be released to the State monitoring program (probation) following release from a State correctional facility. Operator of a Care Facility: We may provide information to an operator of a care facility in which you reside (nursing home, convalescent center) to assist with any special needs.Law Enforcement / Legal Actions: We are required to report incidents of child or adult abuse or neglect and/or provide information as necessary to assist in the investigative process to the police or appropriate social service agency. We may disclose information to the Coroner or Medical Examiner, or limited information may be disclosed to law enforcement as required by law to assist in fulfilling their duties. We may disclose information upon receipt of a Court Order. Furthermore, information related to a client’s commission of a crime at 1740 NE Riddell Rd Ste 110 Bremerton, WA is not protected. In the course of an investigation for involuntary treatment and/or as a result of a civil petition for involuntary treatment: We are authorized to share your information with the county prosecutor, your attorney, the court, Department of Social and Health Services, to a protection and advocacy agency, and others as allowed under the law regarding involuntary commitment proceedings, RCW 71.05 or 71.34. Duty to Warn: We are required to disclose information to the proper authorities (law enforcement)and the intended victim if we suspect serious harm to another is intended or threatened. Oversight: Information may be reviewed by a regulatory or oversight committee to ensure adherence to required guidelines. This may include, but not be limited to, state, federal, and regional audits reviewing business practices, billing procedures, clinical practices, and confidentiality issues. Payments/Benefits: We may disclose information to assist in collecting payment for services or to assist you in accessing benefits/aid. Health Care Providers: We may disclose information to your primary health care provider or community mental health provider for continuity of care (unless directed otherwise), or to assistwith emergency medical treatment or medically necessary tests/evaluations. Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a workforce member orbusiness associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more clients, workers, or the public. All other uses and disclosures of your protected health information will only be made with your written authorization and you may revoke that authorization at any time as provided by 45 CFR 164.508 (b). Filing a Complaint: How to File a Complaint or Report a Problem: If you have questions or would like additional information or feel your privacy rights have been violated and you would like to file a complaint,you may contact my office (360) 567-6109. You may also file a complaint directly with the Office for Civil Rights, U.S. Dept. of Health and Human Services, 2201 Sixth Avenue Suite 900, Seattle, WA 98121. There will be no retaliation for filing a complaint. Professional Records By law and the standards of my profession, it is required that I keep appropriate treatment records which include your diagnosis, dates of your treatment sessions, and the rate at which you were billed. You are entitled to receive a copy of the records, unless I believe that you are reading them would be emotionally damaging, in which case, I will provide them to an appropriate mental health professional of your choice. If you wish, I can prepare an appropriate summary. Because these are professional records, they can be misinterpreted and/or can be emotionally upsetting. If you wish to see your records, I recommend that (if deemed appropriate) we review them in my presence so we can discuss what they contain. You should be aware that you will be billed accordingly for any records copied.
By my signature below I acknowledge receipt of KC Family Hope Center, Karen Casseday, MN, PMHNP-BC, ARNP Notice of Privacy Practices. Effective Date: February 2, 2015. Updated 2/16/2019
What are your goals for treatment?*
What medications are you taking? Name, Dose (MG), how many times per day type "NONE" if not taking any*
List any and all medications that you take and the dosing instructions for each, including any vitamins and/or supplements. It is important to remember to bring this completed list to each appointment, even if nothing has changed since your last appointment.
Possibility of pregnancy*
Yes No Unsure
Diagnoses:*
If no diagnoses type NONE
Surgeries & Dates:*
Inpatient/Outpatient and Dates:*
Recent Illness?*
Pain Location:*
1-10*
10 = overwhelming
Past Medical History*
Diabetes Chest Pain High blood Pressure Heart Disease Heart Attack High Cholesterol Pacemaker Headaches Kidney Stones Kidney Disease Cancer Osteoporosis Asthma/COPD Stroke/CVA/TIA Seizures HIV/AIDS Hepatitis Stomach Ulcer Liver Disease Heart Palpitation Arthritis Heart Surgery Blood Clots Peripheral Vascular Disease Tuberculosis Depression Cognitive Heart Failure None
General:*
Weight loss Weight Gain Insomnia Tiredness Appetite Up Appetite Down Failure to Gain Weight Failure to Thrive Short Statured Too Little Energy Too Much Energy Fevers Night Sweats None
Ears, Nose, Throat:*
Ear Pain Sinus problems Nose bleeds Dry Mouth Sore Throat Hoarseness Wears Braces Blindness Light sensitivity Drooping eyelids Tearing Hearing loss Ringing in ears Tonsilitis Teeth problems Ear infections PE tubes None
Eyes:*
Blurry Vision Eye Redness Poor Vision Dry Eyes Double Vision Wears Glasses Contacts None
Heart:*
Chest Pain Rapid Heart Heart Skips Beats Swelling in legs or feet Cardiac Abnormality Fainted while exercising Abnormal Cardiac Exam Murmur Irregular heartbeat Rheumatic fever Known cardiac abnormality Abnormal cardiac exam Family history of early sudden cardiac death None
Respiratory*
Shortness of breath Chronic Cough Wheezing Pneumonia Nighttime cough None
Stomach and Bowels:*
Nausea Vomiting Diarrhea Constipation Frequent Heartburn Choking Appendicitis None
Bladder and Urine:*
Frequent Urination Loss of Bladder Control Trouble Passing Urine Kidney Failure None
Skin:*
Rash Hair loss Itching Skin Sores/Ulcers None
Blood:*
Easy Bruising Prolonged Bleeding Blood Clots None
Muscles and Joints:*
Joint Pain Back Pain Muscles Aches None
Emotional:*
Anxiety Depression Suicidal Thoughts Anxiety Attacks Hearing Voices Moodiness Irritability Attention/Focus None
Head and Brain:*
Seizures Dizziness/Vertigo Headaches Numbness Traumatic Brain/Head Injury Tremors None
Endocrine:*
Hormone Issues Menses Birth control Heat Intolerance Cold Intolerance Increased Thirst Excess Sweating None
Physical Activity?*
Sports Regular Excersise None
Immune:*
Swollen Glands Runny Nose Frequent Infections None
Allergies:*
Latex Medications Bee Stings Eggs Hay Fever Foods None
Mood:*
Interest (deficit) Guilt (about things done/not done) Energy deficit Concentration (distractible, poor focus, forgetful) Agitation Restless Loss of libido/interest in physical intimacy Low Self Esteem Social Withdrawal Negative feelings towards self or others Persistent physical problems (like being sick often) Reduced Emotional Abilities None
Sleep:*
Stop breathing Snoring Difficulty staying asleep Difficulty falling asleep Fear of going to sleep Movement during sleep Nightmares (with gore) Sleep deficit or need Daytime sleepiness Waking up during the night None
Check all that apply:*
Grandiosity- high/hyper, talking with God, conquer the world Indiscretion- activities causing guilt Talkativeness-pressured speech Anger Racing thoughts Self Abuse Distractibility Flight of ideas Activity/energy Increased Rage Hostility Aggression none
Tobacco:
Cigarettes Cigars Chew
First Use:
Current Use:
Caffeine
Coffee Tea Energy Drinks
Daily Consumption:
Alcohol:*
Beer Liquor None
First Use:
Daily Consumption:
Age first used drugs or alcohol?
Have you ever tried the following:*
Past Use Current Use Never
Alcohol
Methamphetamine
Bath Salts
Spice
Cocaine
Heroin
Ecstasy
LSD or hallucinogens
Marijuana
CBD
Edibles
Not Prescribed:*
Past Use Current Use Never
Pain killers
Methadone
Tranquilizer/sleeping pills
Ketamine
Substance Use: Have you ever been treated for alcohol or drug use or abuse?*
Yes No
If Yes, which substances? When? Where?
Have you ever felt you ought to cut down on your drinking or drug use?*
Yes No
Have people annoyed you by criticizing your drinking or drug use?*
Yes No
Have you felt bad or guilty about your drinking or drug use?*
Yes No
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 (eye-opener)?*
Yes No
Do you think you may have a problem with alcohol or drug use?*
Yes No
What have you used in past 3 months?*
Type NONE if does not apply
Social History:*
Married Divorced Single Living w/ partner Widowed Living w/ children
How long in relationship?
# of kids
Ages of kids:
Who lives with you?*
Type NONE if does not apply
Transgender:
How would you identify your sexual orientation?
Occupational History*
Unemployed Currently working Not working by choice Disabled Retired
Have you served in the military?*
Yes No
If so, What branch and When?
Type NONE if does not apply
Occupation (most recent job)
Significant other's job
Educational Level*
GED High school Grad College Degree
Educational History:*
Special Education Classes Learning Disorders Motivation Difficulty, ability to focus Special Accommodations None
What are your hobbies:*
Please describe your strengths:*
Who is your greatest support?*
Legal history: arrests/incarcerations/probation (charges?)*
Type NONE if does not apply
Assaultive Behaviors: historical and current:*
Type NONE if does not apply
Trauma:*
bullying/bullied physical emotional sexual neglect catastrophic event none
Losses*
Type NONE if does not apply
Stressors:*
School Relationships Family Relationships Social Financial Work None
Spiritual and/or cultural groups you would like to identify?*
Type NONE if does not apply
What is your involvement?*
Type NONE if does not apply
Are there any cultural/spiritual variables that might affect your treatment?*
Type NONE if does not apply
Suicidal thoughts or attempts:*
history of self-harm behavior thoughts of suicide thoughts to harm others None
Have you ever had feelings or thoughts that you did not want to live?*
Yes No
If so, please answer the following. Do you currently feel that you don’t want to live?
Yes No
Do you feel hopeless and/or worthless? Please explain:*
Type NONE if does not apply
Have you ever tried to kill or harm yourself? Please explain:*
Type NONE if does not apply
Family History: (Please list any known medical problems)*
Unknown Adopted
Siblings*
Birth Order Describe Relationship
Brother
Brother
Brother
Sister
Sister
Sister
Problems before or after birth?*
Type NONE if does not apply
Age when left home:*
Where were you born and raised?*
Type unknown if unknown location of birth
Family History*
Thyroid disease Liver disease Sudden Cardiac Death Chronic fatigue Fibromyalgia History of fainting Diabetes Kidney disease Seizures Chronic pain High cholesterol Head trauma None
Your Children(s) Illnesses:
Type NONE if does not apply
Pertinent Medical: (such as sudden early cardiac death) Type NONE if does not apply
Medical Problem
Immediate Family:
Maternal Extended Family:
Paternal Extended Family:
Family Psychiatric History (may have Mental Health issues, history of drug or alcohol use, depression, Bipolar disorder, Anxiety, Anger, PTSD, Schizophrenia, ADHD, Alzheimer's Disease, Manic Depression) Type NONE if does not apply
Family Psychiatric History
Immediate Family:
Maternal Extended Family:
Paternal Extended Family:
Previous Anti-anxiety Medications + Is a positive effect - Is a negative effect
Dose + Effect - Effect
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Buspar (buspirone)
Previous Sedative/Hypnotics + Is a positive effect - Is a negative effect
Dose + Effect - Effect
Ambien (zolpidem)
Sonata (zaleplon)
Lunesta (eszopiclone)
Restoril (temazepam)

Previous Mood Stabilizers + Is a positive effect - Is a negative effect
Dose + Effect - Effect
Lithium
Depakote (valproate)
Tegretol (carbamazepine)
Trileptal (oxcarbamazepine)
Topamax (topiramate)
Lamictal (lamotrigine)
Latuda (lurasidone)
Previous Sedative/Hypnotics + Is a positive effect - Is a negative effect
Dose + Effect - Effect
Desyrel (trazodone)
Remeron (mirtazapine)
Rozerem (melatonin rx)
Melatonin-OTC

Previous Anti-depressants + Is a positive effect - Is a negative effect
Dose + Effect - Effect
Prozac (fluoxetine)
Zoloft (sertraline)
Paxil (paroxetine)
Celexa (citalopram)
Luvox (fluvoxamine)
*Signature will be completed in office*
If the patient is over 13 years old they must sign below to consent to the receive treatment.
Should be Empty:

	Dose	+ Effect	- Effect
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Vyvanse (lisdexamphetamine)
Tenex (guanfacine)
Intuniv (Guanfacine)
Mydayis

	Dose	+ Effect	- Effect
Cymbalta (duloxetine)
Wellbutrin (bupropion)
Remeron (mirtazapine)
Rexulti (brexiprazole)
Savella (milnacipram)
Sinequan (doxepine)
Tofranil (imipramine)
Trintellix (vortioxetine)
Viibryd (vilazodone)
Vivactil (protriptyline)

	Dose	+ Effect	- Effect
Lexapro (escitalopram)
Effexor (venlafaxine)
Anafranil (clomipramine)
Elavil (amitriptyline)
Ensam (selegiline)
Fetzima (levomilnacipran)
Nardil (phenelzine)
Norpramin (desipramine)
Pamelor (nortriptyline)
Pristiq (desvenlafaxine)

	Past Use	Current Use	Never
Alcohol
Methamphetamine
Bath Salts
Spice
Cocaine
Heroin
Ecstasy
LSD or hallucinogens
Marijuana
CBD
Edibles

	Medical Problem
Immediate Family:
Maternal Extended Family:
Paternal Extended Family:

	Dose	+ Effect	- Effect
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Buspar (buspirone)

	Dose	+ Effect	- Effect
Ambien (zolpidem)
Sonata (zaleplon)
Lunesta (eszopiclone)
Restoril (temazepam)

	Dose	+ Effect	- Effect
Lithium
Depakote (valproate)
Tegretol (carbamazepine)
Trileptal (oxcarbamazepine)
Topamax (topiramate)
Lamictal (lamotrigine)
Latuda (lurasidone)

	Dose	+ Effect	- Effect
Desyrel (trazodone)
Remeron (mirtazapine)
Rozerem (melatonin rx)
Melatonin-OTC

	Dose	+ Effect	- Effect
Prozac (fluoxetine)
Zoloft (sertraline)
Paxil (paroxetine)
Celexa (citalopram)
Luvox (fluvoxamine)

	Past Use	Current Use	Never
Pain killers
Methadone
Tranquilizer/sleeping pills
Ketamine

	Birth Order	Describe Relationship
Brother
Brother
Brother
Sister
Sister
Sister

Intake Paperwork

Policies & Procedures

Electronic Communication Policy & Informed Consent