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Personal details
Legal First name*
Legal Last name*
Mobile*
Email address*
Gender at birth*
Male
Female
Referred by*
Web search
Insurance company
Friend and family
Therapist
Medical professional
Existing patient
Other
Address*
City*
State*
Zip code*
Emergency Contact Name*
Phone No
Emergency Contact Relationship
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Date of birth*
Name of person completing form and relationship to patient*
Reason for appointment*
Current medications and dosage*
List any medical allergies*
Primary Care Physician (Name, Phone, Address)
Preferred Pharmacy
Name
Phone No
Address
City
State
Zip
Is patient a minor?*
Yes
No
Is patient a minor?*
Married
Separated
Divorced
Patient not a minor
Legal Guardian(s) (if applicable)
Preferred Phone No
Cell
Home
Work
Secondary Phone No
Cell
Home
Work
Email Address
Patient/Guardian's Name
Patient/Guardian's Signature
Date
Do you have any current or pending legal issues or are being advised by a court judge,parole officer, or CPS to seek mental health care or assessment?*
Yes
No
Please select if you have ever experienced or suffered from any of the following in the past or present? (check one or all that applies)
Thoughts of harming others*
Past
Present
No
Suicide ideation*
Past
Present
No
Alcohol abuse*
Past
Present
No
Substance abuse*
Past
Present
No
Are you using insurance?*
Yes
No
Insurance provider*
Insurance provider*
Group #(if applicable)
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3400 Douglas Blvd.
Suite 225 Roseville, CA 95661
Phone:
(855) 446-8628
Email:
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