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Personal details

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Gender at birth*MaleFemalePrefer not to say

Date of birth*

Emergency Contact Name*

Phone No*

Emergency Contact Relationship

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

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Address

City

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Appointment type *Initial consultation visitFollow-up visit

Is patient a minor ?*YesNoDo 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?*YesNoPlease select if you have ever experienced or suffered from any of the following in the past or present? (check that applies)Thoughts of harming others*YesNoSuicide ideation*YesNoAlcohol abuse*YesNoSubstance abuse*YesNo

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