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Medication Management
Psychotherapy/counselling/Duo Diagnosis
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First Name
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Last Name
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Date of Birth
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Address
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City
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Zip
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Phone Number
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Email
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Primary Insurance
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Primary Insurance ID
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Secondary Insurance (If Any)
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Secondary Insurance ID
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Name of Company (If alternate mental health services provider stated on card)
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Copay
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Primary Care Physician
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Referred By
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Why are you seeking help?
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Past inpatient hospitalizations in the last 6 months-1 yr (Diagnosis &treatments).
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Past outpatient services and Providers 6 months-1yr (Diagnosis, Treatment)
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Current Psychotropic Medications
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Substance Use/Abuse issue
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Current Controlled Substance use
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