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Date Of Birth *
Email *
Phone Number *
Address *
Are You Currently Employed? * --- Select Choice --- Yes No
Occupation *
Name of Employer *
Preferred Gender * --- Select Choice --- Female Male Other
Preferred Pronouns *
Sex Assigned at Birth * --- Select Choice --- Female Male
Relationship Status * --- Select Choice --- Single Partnered Married Divorced Widowed
Name of Significant Other (If Applicable)
Emergency Contact Name *
Emergency Contact phone Number *
Relationship To Patient *
Preferred Pharmacy *
Primary Care Physician Name *
Referred to NP Associates by (If Applicable)
Are You Currently Seeing Any Other Mental Health Professional? * --- Select Choice --- Yes No
If Yes to Above, Please List Their Name and Phone Number
Are You Allergic to Any Medications? If So, Please List Any Drug Allergies Below *
Please List All current PSYCHIATRIC Medications. Please Include Dosage, How Long You Have Been Taking Them, And Any Side Effects You Have Experienced *
Please List All current NON-PSYCHIATRIC Medications. Please Include Dosage, How Long You Have Been Taking Them, And Any Side Effects You Have Experienced *
Please List All current PREVIOUS PSYCHIATRIC Medications. Please Include Dosage, How Long You Have Been Taking Them, And Any Side Effects You Have Experienced *
PATIENT MEDICATION ACKNOWLEDGMENT: The purpose of this section is to outline office policies regarding prescription medications that may be prescribed as part of your treatment plan. These medications may include controlled substances such as pain medications, stimulants, or sedatives. Our goal is to provide safe, effective care while minimizing the risks associated with prescription medications. I understand that I may be prescribed prescription medication(s) as part of my treatment and agree to the following: I will take medications only as directed by my provider. I will inform my provider of any medications I am currently taking, including prescriptions from other physicians or urgent care/emergency visits. I understand that the office may request urine or laboratory screening as part of ongoing treatment. I agree to use one pharmacy for prescription medications whenever possible and will notify the office if my pharmacy changes. I understand that prescription medications should not be shared with others. I agree to store medications safely to help prevent loss, misuse, or theft. I understand that some medications may cause drowsiness, impaired coordination, or slowed reaction times, which may affect driving or operating machinery. I agree to attend scheduled appointments and follow treatment recommendations. I understand that medication treatment plans may be adjusted, reduced, or discontinued based on medical judgment, safety concerns, or misuse concerns. I authorize communication between this office, my pharmacy, and other healthcare providers involved in my care as necessary for treatment purposes. I understand that prescription refills may not be available after office hours, on weekends, or on holidays. * --- Select Choice --- I have read and understand this acknowledgment.
Policy #
Group #
If There is a Responsible Party Signing On Behalf Of The Patient, Please List Your Name, Phone Number, and Relationship To The Patient Below
Please Tell Us The Reason For Your Appointment *
Please Tell Us Any Previous Psychiatric Experience *
Have You Previously Been Hospitalized For A Psychiatric Reason? If Yes, Please Tell Us More About The Reason and Experience
Please List Previous Providers Of Care Including Psychiatrists and Psychotherapists *
Please List Any History Of Treatment For Drug and Alcohol Abuse *
Other
If You Have Had Injuries Of A Serious Nature, Please List Below *
Family History: Please List the Names of Your Immediate Family (Mother, Father, Siblings, Children). If They Are Not Living, Please Indicate Cause of Death *
Are There Any Known Psychatric Illnesses in Your Immediate Family? If So, Please Provide Details Below *
Please List Any Important Facts Concerning Your Childhood and Adolescence *
Please Tell Us About Your Education Up To This Point (If You Went To College, Where, ETC) *
Who Do You Currently Live With? *
or Happened A
FOR OFFICE USE ONLY: PATIENT PQ9 SCORE
FOR OFFICE USE ONLY: PATIENT GAD-7 SCORE
If You Checked Off ANY Problems, How Difficult Have These Problems Made It For You To Do Your Work, Take Care Of Things At Home, Or Get Along With Other People? * --- Select Choice --- Not Difficult At All Somewhat Difficult Very Difficult Extremely Difficult
How Much Of A Problem Did Any Of These Cause You - Like Being Ability to Work, Having Family, Money, or Legal Issues, Arguments or Fights? * --- Select Choice --- No Problems Minor Problems Moderate Problems Serious Problems
Have Any of Your Blood Relatives (Children, Siblings, Parents, Grandparents, Aunts, Uncles) Been Diagnosed with Bipolar Disorder or Manic-Depressive Illness? * --- Select Choice --- Yes No I'm Not Sure
Has A Health Professional Ever Told You That You Have Manic-Depressive Illness or Bipolar Disorder? * --- Select Choice --- Yes No I'm Not Sure
