Hope & Faith Wellness Clinic - Intake Form
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Email *
First Name *
Middle Initial *
Last Name: *
DOB: *
MM
/
DD
/
YYYY
SSN:
Gender: *
Marital Status: *
Address: *
City: *
State: *
Zip Code: *
Phone Number: *
Referring Physician Name:
Referring Physician Number:
Weight:
Height:
Current Issues:
Ever received counseling?:
Clear selection
Select Symptoms:
Mild
Moderate
Severe
Aggression
Agitation
Anger
Anxiety
Appetite change
Change in libido
Compulsions
Crying/tearful
Cyber addiction
Delusions
Depression
Disorientation
Difficulty getting out of bed
Difficulty making decisions
Distractibility
Eating disorder
Judgment errors
Loneliness
Loss of interest in activities
Physical trauma perpetrator
Clear selection
Family Psychiatric History: *
If yes:
Please state the mental condition(s)
Current psychiatric medications:
Allergies:
Non-psychiatric conditions:
Please list any non-psychiatric medical conditions for awareness.
Smoke? *
Alcohol? *
If yes (How often):
Take illegal substance(s)?:
If yes, please tell us about it in details
Do you have any suicidal thought?: *
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