WTJ and Associates | Beyond Wellness

Patient Name

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState

Zip Code

Contact Number

Format: (000) 000-0000.

Type of Number

Email Address

example@example.com

Insurance Company

Insurance Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Policy Number or Member ID

Group Number

Insured Name

Primary Care Doctor Name

First NameLast Name

Primary Care Doctor Office Number

Last Date of Physical

Date

What are the current issues that you are experiencing now? For example, relationship, work related, health concerns, anxiety depression. Please explain below:

Are you currently seeing a Therapist:

Have you received outpatient treatment before?

If yes, please describe when, by whom, and nature of treatment.

Please include the Physician Name, Reason for Treatment, Dates Treated (Month/Year)

Have you ever been hospitalized for psychiatric reasons?

If yes, please describe when, by whom, and nature of treatment.

Please include Facility/Hospital Name, Dates of Admission (Month/Year), Reason for Hospitalization, Duration of Stay

Have you ever been on psychiatric medications?

If yes, please list medications taken.

Please include the dates, dosage and how helpful they were

How often do you consume alcohol?

Do you use any kind of tobacco or have you ever used them?

Do you have a history of substance use?

Please provide details to the 3 questions above.

Please include the type (alcohol or drug), if you were treated and when, and how often of use

Who raised you during most of your childhood?

How would you describe your childhood?

Do you have any siblings?

If yes, how many?

How would you describe your relationship with your family today?

Current Relationship Status:

If currently in a relationship, how long have you been together?

How would you describe your current relationship(s)?

Do you have any children?

If yes, please list their ages:

Highest level of education completed:

Current employment status:

Occupation:

How satisfied are you with your current work/school situation?

Are work, school, or financial concerns contributing to your current stress?

If yes, please explain:

Signature

WTJ and Associates | Beyond Wellness

Health Insurance Information

Past Psychiatric History

Social History