Intake Form

Helping us understand your needs and provide better care.

Intake Form

Please complete the following information to help us better understand
your healthcare needs and provide personalized, compassionate care.

Complete this form to help us
provide the care and support you need.

* Required Information

PATIENT REGISTRATION

First Name *

Middle Name *

Last Name *

Residential Address *

City *

State/Province *

Zip Code *

Home Phone Number

Mobile Phone Number *

Work Phone Number

Current Employer

Social Security ID

Date of Birth *

Current Age *

Sex *
MaleFemale

Marital Status *

Ethnicity *

Email Address *

EMERGENCY CONTACT

Full Name *

Phone Number *

GUARDIAN DETAILS (FOR PATIENTS UNDER 18 YEARS OLD)

Guardian Full Name

Relationship to Patient

Home Phone Number

Mobile Phone Number

Work Phone Number

FINANCIAL AND POLICYHOLDER DETAILS

PRIMARY INSURANCE INFORMATION

Insurance Company

Policy Number

Group Number

Effective Date

Policyholder Name

Policyholder Social Security Number

Policyholder Birthdate

Relationship to Patient

Policyholder Address

City

State

Zip Code

Policyholder Phone

Sex
MaleFemale

SECONDARY INSURANCE INFORMATION

Insurance Company

Policy Number

Group Number

Effective Date

Policyholder Name

Policyholder Social Security Number

Policyholder Birthdate

Relationship to Patient

Policyholder Address

City

State

Zip Code

Policyholder Phone

Sex
MaleFemale

What concern(s) brought you to this psychiatry clinic? *

What has been causing your stress recently (e.g. family, work, recent loss, financial difficulties)? *

Are you experiencing any of the following issues? *

Mood and Emotional ConcernsPhysical and Energy-Related ConcernsAnxiety and Stress Related ConcernsAttention and Hyperactivity ConcernsPerception and Paranoia ConcernsSubstance Use ConcernsEating and Nutrition ConcernsCognitive and Memory Concerns

Have you ever been diagnosed with any mental health disorder by a healthcare professional? *
YesNo

Have you ever consulted with a psychiatrist, therapist, or counselor? *
YesNo

Have you ever been admitted to a hospital for psychiatric treatment? *
YesNo

Have you ever received treatment using psychiatric medication or mental health medications? *
YesNo

Are there any other psychiatric medications you have used?

MEDICAL CARE INFORMATION

Do you have a regular primary care physician? *
YesNo

What health conditions have you been diagnosed with?

What surgical procedures have you undergone?

List any medications you take, including prescriptions, over-the-counter drugs, herbal remedies, or supplements.

Describe any allergies you have (such as to medications or foods).

Are you experiencing or have you recently experienced any physical symptoms?

FOR WOMEN

Date of your last menstrual period

Are your menstrual cycles usually regular?
YesNo

Are you currently using any form of birth control?
YesNo

Have you ever been pregnant?
YesNo

Have you experienced any miscarriages?
YesNo

Have you had any episodes of depression or suicidal thoughts related to pregnancy?
YesNo

HISTORY OF SUBSTANCE USE

How frequently have you engaged with any of these substances?

Have you experienced any legal problems (arrests, charges, imprisonment)? If yes, please provide details.

Have you ever been a victim of a violent crime?
YesNo

Have you ever suffered from physical abuse, emotional abuse, or sexual abuse as a result? If yes, please explain.

SAFETY

Are you currently experiencing thoughts of self-harm? *
YesNo

Have you attempted to harm yourself in the past? *
YesNo

Are you having any thoughts of harming others? *
YesNo

Have you ever tried to hurt someone else before? *
YesNo

I certify that the information provided is true and accurate to the best of my knowledge.

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any information I submit on behalf of others, for the purposes of evaluation and fulfilling my request and related business purposes. I understand this information will be handled in accordance with the Privacy Notice.

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Intake Form

Helping us understand your needs and provide better care.

Intake Form

Complete this form to help us
provide the care and support you need.

240-564-5989

info@minnettehealthcare.com

Intake Form

Intake Form

Helping us understand your needs and provide better care.

Intake Form

Complete this form to help us provide the care and support you need.

240-564-5989

info@minnettehealthcare.com

Intake Form

Complete this form to help us
provide the care and support you need.