PATIENT REGISTRATION FORM

PATIENT INFORMATION
First Name

Last Name
Patient Date of Birth (MM/DD/YYYY):
Mailing Address
Street
City
State
Zip Code
Patient Gender:
Marital Status:
Email Address: Occupation:
Cell Phone Number:
Referred to Clinic By:

Primary Care Provider (PCP) Name: PCP Phone Number (if known):
EMERGENCY CONTACT (Please list anyone you authorize to receive protected health information)
First Name
Last Name
Relationship to Patient: Phone Number:
INSURANCE INFORMATION
Primary Insurance Company: Policy/ID Number: Group Number:
Secondary Insurance Company: Policy/ID Number: Group Number:
Click Here For Patient Rights
Notice of Privacy Practices
SIGNATURE
Patient Signature:
Signature 1


Date:

Medical History & Intake Form


Patient Name:
First Name
Last Name
Date of Birth (MM/DD/YYYY):
Age:
Marital Status:

Occupation:

Gender:
Are you pregnant?
Are you breastfeeding?
List your sexual orientation:
I am looking for help with:

List any mental health conditions you have been diagnosed with:

Have you tried any psychiatric medications in the past? If so, please list them.

Are you currently taking any prescription medications?

Do you have any allergies to any medications?

Have you had any surgeries in the past?

Have you been diagnosed with any medical conditions?

If you answer yes to any of the following questions, please explain below:

Have you ever attempted to end your life?

Have you harmed yourself intentionally?

Have you been diagnosed with autism?

Have you ever been to a rehab for drug abuse?

Have you ever been diagnosed with asthma?

Have you ever been diagnosed with glaucoma?

Have you been diagnosed with hyperthyroidism?

Do you have kidney problems?

Are you taking opioids or using street opioids?

Have you been diagnosed with diabetes?

Do you regularly use Tramadol?

Have you been hospitalized at a psychiatric hospital?

Have you ever been diagnosed with a delay?

Do you suspect you have autism?

Have you ever been to a rehab for alcohol abuse?

Do you have cataracts?

Have you ever been diagnosed with hypertension?

Have you ever had any heart problems?

Have you been diagnosed with hypothyroidism?

Do you have liver problems?

Have you had seizures in the past?

Are you taking anti-coagulants (blood-thinners)?

Are you currently or have you ever used street meth?

Have you ever been diagnosed with arteriosclerosis or cardiovascular disease?

Have you ever been diagnosed with a structural cardiac abnormality?

Has anyone in your family ever had a sudden cardiac death?

Have you ever been diagnosed with a heart arrythmia?

Have you ever had a heart attack?

Have you ever been diagnosed with sleep apnea?

Have you ever been arrested? If so, list charges.

Are you currently on probation or parole?

No-Show & Cancellation Policy

A “no-show” is an appointment for which you do not show up. It also includes when you change or cancel an appointment less than 48 business hours before your scheduled time

WE DO NOT OFFER GRACE PERIODS. We recommend you arrive 10-15 minutes before your scheduled appointment time. If you arrive after your scheduled appointment time, you will be required to pay the no-show fee and you will be rescheduled for a different time/date.

There is a $50 charge for each no-show or change less than 48 business hours before your scheduled time.

The fee is charged to the patient, not the insurance company, and is due before scheduling another appointment.

As a courtesy, when time allows, we make reminder calls for appointments. If you do not receive a reminder call or message, the above policy will remain in effect.

I have read and understand the medical appointment cancellation/no show policy and agree to its terms.





Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Patient Name First Name:
Last Name:
Today’s Date
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
7. How often do you make careless mistakes when you have to work on a boring or difficult project?
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?

Mood Disorder Questionnaire

Name: First Name:
Last Name:
Date
Please answer the questions as best you can by putting a check in the appropriate box.
Has there ever been a period of time when you were not your usual self and...
… you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
… you were so irritable that you shouted at people or started fights or arguments?
… you felt much more self-confident than usual?
… you got much less sleep than usual and found that you didn’t really miss it?
… you were more talkative or spoke much faster than usual?
… thoughts raced through your head or you couldn’t slow your mind down?
… you were so easily distracted by things around you that you had trouble concentrating or staying on track?
… you had much more energy than usual?
… you were much more active or did many more things than usual?
… you were much more social or outgoing than usual; for example, you telephoned friends in the middle of the night?
… you were much more interested in sex than usual?
… you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
… spending money got you or your family into trouble?