Waypoint Wellness Center

New Patient Registration Form

Name:

Nickname:

Date of Birth:

Gender

(circle)   M      F

Address:

Phone: (H)

Okay to leave message?

Yes     No

              (C)

Okay to leave message?

Okay to text message?

Yes     No

Yes     No

        (other)

Okay to leave message?

Yes     No

Primary Care Physician:

Phone:

Primary Care Physician

Address:

Referral Made by Physician?

 Y  /  N

Insurance Provider:

Insurance Holder:

Date of Birth:

Insurance Policy Number:

Group Number:

Occupation

How long?

In case of emergency:

Name of local friend/relative:

Relationship to patient:

Phone Number

Status of Parents

Married

Divorced

Remarried

Never

Married

Deceased

M / D

How long married?

Your age at divorce?

Siblings

Ages

What brings you to therapy? What are your primary concerns?

Previous Evaluations/Treatment (Psychiatric, Psychological, Therapy, etc.):

Name of Provider

Type of treatment

Dates of Service

Contact Information

Please provide a copy of any past psychological reports.

Medical Issues:

Hospitalizations

Chronic Medical Conditions

Allergies

Current Medical Concerns

Head trauma/Loss of consciousness

Corrective lenses/Hearing problems

Medications:

Name of Medication

Dose

Effectiveness

Past/Present

Family History of Medical/Psychological Issues (Please check)

Condition

Mom

Dad

Sibling 1

Sibling 2

Other

ADHD

Anxiety

Depression

Bipolar Disorder

Behavior Problems

Learning Disabilities

Drugs/Alcohol

Autism

Psychiatric Hospitalizations

Other:

Any significant issues with pregnancy, birth or early development?

Educational History (please circle)

How far did you go in school?

Did you ever receive special education services?

Yes

No

Did you have an IEP or 504 plan?

IEP

504

Please describe your personal strengths and interests: