Mental Health Intake Form | Assurance Care Health

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Assurance Care Health
About
- Psychology Today
  - Provider 1
  - Provider 2
Services
- Membership / Fee
Telehealth
- Appointment
Contact Us

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INTAKE FORM

Before we get started, we need to collect some general information from you.

KINDLY FILL THE FORM BELOW OR DOWNLOAD HERE & SEND THE COMPLETED COPY TO assurancecarehealth@gmail.com.

GENERAL INFORMATION

First Name

Last Name

Gender

Birth Date

Address(Line 1)

Address(Line 2)

City

State

Zip Code

Main Phone

Other Phone

EMERGENCY CONTACT

First Name

Last Name

Phone

Relationship

Do you authorize this person to discuss care or treatment with the office in the case of an emergency?

Yes No

MENTAL HEALTH HISTORY/STATUS

What problems are you seeking help for?

Past Mental Health Treatment

Have you ever been hospitalized for psychiatric reasons?

Yes No

If yes, when and where?

Have you ever had outpatient treatment by a psychiatrist?

Yes No

If yes, when and by whom?

Have you ever received counseling or psychotherapy in the past?

Yes No

If yes, when and by whom?

Please List any psychiatric medication you have taken or are taking: (Medication Date/Side Effects/Benefits)

Please Check all that apply:

Depressed mood Lost or gained weight Not enough sleep Too much sleep Sluggish Agitated Never tired Cannot concentrate Afraid to leave home Inflated self esteem Feel guilty or worthless Excessive talking Racing thoughts Easily distracted Over working yourself Impulsive behavior See/hear things that are not real Suspect things may not be real Tense/unable to relax Excessive worry Panic attacks Thoughts of death or suicide Unreasonable fear Fear of social situations Repetitive thoughts/behavior Upsetting memories Recent loss/grief Work/school problems Violent thoughts/behaviors Self-harm Anger outburst Careless, high-risk behavior Financial problems

Please list any additional notes that you think would be helpful for treatment below:

Assurance Care Health
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+1 (877) 920-1880
assurancecarehealth@gmail.com

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