Patient Intake Form
Please Provide Answers To All Questions (If No Answer Is Applicable Please Just Write N/A)
Email address *
By Checking The Box Below, I Attest that I Have You Read and Understand The Office Policies of RVA Psychiatry and Wellness, LLC.. (Online: https://www.rvawell.com/about-1.html ) *
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By digitally typing/signing below I authorize RVA Psychiatry and Wellness, LLC / Robert "Trip" Young, NP to charge my credit/debit card for all services including any cancellation or no-show fees. (Please write name as appears on credit card) *
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Full Name *
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Date of Birth *
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Credit Card Number *
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Credit Card Expiration *
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Credit Card CVV *
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Credit Card Zipcode *
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Phone Number *
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Home Street Address *
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Emergency Contact and Phone Number (And Your Relationship With That Person) *
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If You Are 26 and Under, Please Provide The Full Name and Phone Numbers of Both Parents (if applicable) *
Your answer
Does Robert "Trip" Young, NP and/or RVA Psychiatric Have Permission To Discuss Your Treatment With Your Emergency Contact and/or Parents? *
Required
How Were You Referred To RVA Psychiatric and/or Robert "Trip" Young? *
Your answer
What Mental Health or Other Struggle Are You Seeking Treatment For? *
Your answer
Do You Currently or Have You Had A History Of Suicidal Thinking or Self-Harm Struggles (Please Explain Current and Past, if applicable) *
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Do You Currently or Have You Had A History Of Homicidal Thinking (Please Explain Current and Past, if applicable) *
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Do You Currently or Have You Had A History Of Auditory or Visual Hallucinations, Paranoia or Delusional Thinking (Please Explain Current and Past, if applicable) *
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Please Provide Current Therapist Information (Name, Address, Phone, Fax) *
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Does Robert "Trip" Young, NP and/or RVA Psychiatric Have Permission To Discuss Your Treatment With Your Current Therapist? *
Required
Your answer
What Coping Skills Do You Have and How Have They Been Effective? *
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Please provide name of primary health provider or names of any medical health professional you seek treatment for, if applicable (Name, Address, Phone, Fax) *
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Please provider information of previous Psychiatric Provider , if applicable (Name, Address, Phone, Fax) *
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Have you ever been discharged from a psychiatric provider or primary care provider for non-treatment compliance? *
Required
If Yes, please explain the circumstances. *
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Have you ever been hospitalized for psychiatric reasons? *
Required
If yes, please explain circumstance and give approximate dates. *
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Do You Have Trauma History (Physical, Sexual, Emotional Abuse) *
Required
If you have trauma history is it physical, sexual, emotional or other. Please just put P, S, E, and/or O without further details. *
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Do You Have Any Medical Allergies? *
Required
Please describe allergy, the reaction, and severity. *
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Have you ever had a seizure? *
Required
Have you ever had a concussion or traumatic brain injurty? *
Required
Describe briefly seizure history, concussion, or TBI (if applicable) *
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Family Psychiatric History (please list blood relatives and known/suspected diagnosis) *
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Please List Current Psychiatric Medications (include response and side effects if applicable) *
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Previous Psychiatric Medications (include approximate dates, response, and side effects if applicable) *
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Please List Any Non-Psychiatric Medical Conditions. *
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Please List Any Non-Psychiatric Medical Conditions for Your Immediate Family (Parents, Grandparents, SIblings) *
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Please List Current Non-Psychiatric Medications, (Including dosages and frequency taken). *
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Please list any over the counter medications or supplements of any kind you are taking. *
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Do You Have Regular Headaches, Chronic Pain Struggles, or Other Chronic Ailments You Are Not Medically Treated For (if yes, please describe) *
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Do You Ever Use Alcohol *
Required
Described The Frequency and Quantity of Alcohol (if applicable) *
Your answer
Do You Ever Use Drugs or Other Substance, Legal or Illegal, In a Non-Prescribed Manner *
Required
Describe Drug and/or Other Substance Use *
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Have You Ever Sought Treatment for Alcohol, Drug, or Other Substance Abuse? *
Required
Please Explain Treatment Received for Drug/Alchol Abuse Struggles (if applicable) *
Your answer
Have You Ever Used Psychiatric or Other Prescription Medications Not As Prescribed or Overused? *
Required
Describe The Above Use of Psychiatric Medications (If Applicable) *
Your answer
Regarding alcohol, drugs or other substances has anyone every told you to... *
Yes
No
Someone or yourself felt you needed to cut back on your alcohol or substance use
Felt angry or annoy when someone confronted you about alcohol or substance use
Felt guilty about your alcohol or substance use and how it may have effected yourself or others
Had an eye opening experience like a DUI or legal trouble related to alcohol or substance use
Have You Read and Understood The Controlled Substance Contract Included In The Office Policies? *
Required
Do You Use Tobacco Products *
Required
Have You Used Tobacco Products In The Past? *
Required
Please described Use Current Or Previous Of Tobacco Products *
Your answer
Do You Daily Use Caffeine, Energy Drinks, or Soda *
Required
Describe Your Approximate Use of Caffeine, Soda, or Energy Drinks. *
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Describe Your Relationship With Your Parents (Please add first names, if applicable) *
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Do you have any children? If so, what ages and how is your relationship with them and how are they doing? *
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Describe Your Relationship With Your Siblings (if applicable) *
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Describe Your Relationship With Your Friends *
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Are You Currently Dating, Married, Other (Please describe quality of relationship, first name of individual if applicable) *
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Describe Your Spirituality -Religion, Spiritual, Atheist, Agnostic, Other? *
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Do You Have Health Insurance *
Required
Are You Currently Employed? *
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If working, what do you do for work? *
Your answer
How would you rate the satisfaction from your current employment? *
Would You Describe Yourself As Financially Stable? *
Required
How would you describe any financial stress in your life? *
Do You Have Any Current or Previous Legal Trouble *
Required
Describe Current or Previous Legal History *
Your answer
Exercise, Do You Exercise At Least 30 Min 5 Times Per Week (Including Walking At Work) *
Required
Exercise, Describe Your Weekly Exercise Routine (if applicable) *
Your answer
Nutrition, Provide A Representation of Your Normal Diet for a 24hr Period *
Your answer
Nutrition, Do You Eat At Least 3-5 Servings of Fruits Vegetables At Least 5 Days Of The Week
Nutrition, Would You Describe The Majority Of Your Meals As Containing Primarily Fresh Ingredients, Including Frozen Not Processed Foods *
Required
Nutrition, Have you Ever Struggled With Disordered Eating *
Required
Nutrition, If Yes to The Above, Please Describe Type of Struggle and Any Treatments for This *
Your answer
Nutrition, Do You Have Any Ongoing Gastro-Intestinal Issues, Regular Upset Stomach, or Other GI Discomforts (If yes, please describe) *
Your answer
Sleep, how many hours of sleep do you get per night (on average) *
Your answer
Sleep, How would you describe the quality of sleep you are getting? *
Sleep, Do you have an evening routine for sleep that is the same every night? *
Did You Have Any Developmental Delays As A Child *
Required
Were There Any Pregnancy Complications During Your Birth? *
Required
What Are Your Personal Goals for 1 yr, 5 yr, and 10 yrs *
Your answer
Describe Any Developmental Delays or Pregnancy Complications. *
Your answer
By digitally typing/signing your name below, I attest that all the information provided is accurate to the best of my knowledge. I have read and understand the office policies, and authorize RVA Psychiatry and Wellness, LLC and/or Robert "Trip" Young, NP to charge my credit/debit card for all services including cancellation or no-show fees. (Please write your full name below) *
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