First Name

Last Name
Patient Date of Birth (MM/DD/YYYY):
Mailing Address
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:
Guarantor on Account (eg, responsible parent if patient is a minor):
First Name
Last Name
Primary Insurance Company: Policy/ID Number: Group Number:
Secondary Insurance Company: Policy/ID Number: Group Number:
Patient / Guardian Signature:
Signature 1


Medical History & Intake Form

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

List your profession:

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)?

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 24 hours before your scheduled time.

Effective August 12, 2019, there will be a $30 charge for each no-show or change less than 24 hours before your scheduled time.

The fee is charged to the patient, not the insurance company, and is due at the time of the patient’s next office visit.

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.

Click Here For Patient Rights
Notice of Privacy Practices

Acknowledgement of Review of Notice of Privacy Practices

Upper Valley Behavioral Health LLC

I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.

NICHQ Vanderbilt Assessment Scale—PARENT Informant

Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child’s behaviors in the past 6 months.

Is this evaluation based on a time when the child

Today’s Date: Child’s First Name: Child’s Last Name: Date of Birth:
Parent’s Name: First Name: Last Name: Parent’s Phone Number:
1. Does not pay attention to details or makes careless mistakes with, for example, homework
2. Has difficulty keeping attention to what needs to be done
3. Does not seem to listen when spoken to directly
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
5. Has difficulty organizing tasks and activities
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
8. Is easily distracted by noises or other stimuli
9. Is forgetful in daily activities
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when remaining seated is expected
12. Runs about or climbs too much when remaining seated is expected
13. Has difficulty playing or beginning quiet play activities
14. Is “on the go” or often acts as if “driven by a motor”
15. Talks too much
16. Blurts out answers before questions have been completed
17. Has difficulty waiting his or her turn
18. Interrupts or intrudes in on others’ conversations and/or activities
19. Argues with adults
20. Loses temper
21. Actively defies or refuses to go along with adults’ requests or rules
22. Deliberately annoys people
23. Blames others for his or her mistakes or misbehaviors
24. Is touchy or easily annoyed by others
25. Is angry or resentful
26. Is spiteful and wants to get even
27. Bullies, threatens, or intimidates others
28. Starts physical fights
29. Lies to get out of trouble or to avoid obligations (ie,“cons” others)
30. Is truant from school (skips school) without permission
31. Is physically cruel to people
32. Has stolen things that have value
33. Deliberately destroys others’ property
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)
35. Is physically cruel to animals
36. Has deliberately set fires to cause damage
37. Has broken into someone else’s home, business, or car
38. Has stayed out at night without permission
39. Has run away from home overnight
40. Has forced someone into sexual activity
41. Is fearful, anxious, or worried
42. Is afraid to try new things for fear of making mistakes
43. Feels worthless or inferior
44. Blames self for problems, feels guilty
45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”
46. Is sad, unhappy, or depressed
47. Is self-conscious or easily embarrassed
48. Overall school performance
49. Reading
50. Writing
51. Mathematics
52. Relationship with parents
53. Relationship with siblings
54. Relationship with peers
55. Participation in organized activities (eg, teams)