Intake Form
Please fill out this intake to the best of your ability. Thank you.
First Name *
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Last Name *
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Date of Birth *
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Address/Street *
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Apartment/Suite
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City *
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State *
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ZIP *
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Home Phone
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Mobile Phone *
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Work Phone
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Medical Insurance *
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Referred By (Please specify: Google, Facebook, Twitter, Instagram, etc.) *
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Primary Care Physician *
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Reason for Appointment *
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Psychiatric/Medical History *
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Current Medications (Medical and Psychiatric) *
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Are you currently seeing a therapist? *
History of Hospitalizations *
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Medication History *
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History of Violence and Suicidal Attempts *
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History of Drug/Alcohol Dependence and Methadone Maintenance *
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History of Addiction Treatment *
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Legal History *
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Current Employer *
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E-Mail Address *
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Questions for M.D. *
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