Initial Information Forms for TeleMental Health Treatment (TMH)
Please allow about 20 minutes to read and fill out this paperwork prior to your appointment.
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Email *
Today's Date *
MM
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DD
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YYYY
Client Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Sex *
Mailing/Street Address *
City/State/Zip *
Home Phone
Work Phone
Cell Phone *
Emergency Contact #1 Name *
Emergency Contact #1 Phone *
Select All that Apply *
Required
Other Providers of Health and Mental Health Services
Primary Care Physician (PCP) Name *
Address
City/State/Zip *
Phone
Psychiatrist Name
Address
City/State/Zip
Phone
Other Counselor Name
Address
City/State/Zip
Phone
Local Resources
Primary Contact Person
Address
City/State/Zip
Phone
Email
Relationship
Comments
Local Counseling Resource Name
Address
City/State/Zip
Email
Phone
Comments
Local Police Department Name *
Phone *
Nearest Hospital Emergency Room Name *
Address
City/State/Zip *
Phone *
Comments
Nearest Psychiatric Hospital Name
Address
City/State/Zip
Phone
Comments
Local DFACS Office Phone Number *
Other Contact Name
Describe
Other Comments
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