Client Questionnaire It’s easy to submit your client questionnaire online. Just fill out and submit this form. Step 1 of 5 20% Notice of Privacy PracticesPatient/Client Name*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Notice of Privacy Practices* I hereby acknowledge that I have received and have been given an opportunity to read a copy of The Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Karen Chinca at 617-739-7190.Signature*I am Signing as:*The ClientA Parent, Guardian, or Personal RepresentativeSignature of Parent, Guardian, or Personal Representative*If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.):*Receipt Refusal Patient/Client Refuses to Acknowledge Receipt Office PolicyFees and Insurance My fee is $185.00 per 45-minute individual session, $195 per 45-minute family session, and $210 for an initial 60-minute evaluation. Payment is due at the time of service, unless otherwise agreed upon. I will provide you with a detailed invoice if you choose to submit the claim to your insurance. Cancellations and Missed Appointments You will be charged the full-out-of-pocket fee of $185 per individual session and $195 per family session for missed appointments that are not cancelled at least 48 hours in advance. If your appointment is on a Monday, you must cancel your appointment by 5PM on the Friday prior to the appointment. Missed and late cancelled appointments are not billable to your insurance company. Phone Consults, Check Ins, Case Management, and Treatment Team Collaboration I am available to speak by phone between sessions if we have a scheduled time to talk. The first 15 minutes are free of charge, and after that, the rate is $45 per 15-minute increment. This includes phone check ins with clients and/or family, case management, and calls with other providers for collaborative care beyond the initial collaborative call/interaction. Emergencies and Coverage I am reachable through my office phone number, (617) 739-7190. If you are in crisis please go to a hospital emergency room or psychiatric emergency service. If you need to speak to me between appointments, but it is not an emergency, please call my voice mail and I will return your call within 24 hours of your message. When I am away and not reachable, I will have another clinician available in case of emergency, whose name and number will be on my voice mail. Confidentiality For information about privacy and confidentiality, please see the Notice of Privacy and Confidentiality Practices, which is consistent with state and federal privacy regulations.Office Policy Acknowledgement* I acknowledge that I have received a copy of the Office Policy, and agree that I am responsible for payment for missed or late cancelled visits, and for visits not covered by my health insurance. Name First Last SignatureDate Date Format: MM slash DD slash YYYY Authorization for Release of Confidential Information/RecordsI hereby authorize Karen Chinca, LICSW: to disclose to and/or obtain from:Name of Requesting or Releasing Individual or AgencyTheir Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Their Phone/FaxTheir Email The information may include: Telephone conversations regarding diagnosis and treatment Psychiatric evaluations and discharge summaries Medical records Other Please List*Acknowledgements I have carefully read and understand the above statements and do hereby expressly and voluntarily consent to disclosure of the above information and/or medical records to those persons/agencies named above. This authorization may pertain to information related to alcohol and drug use/addiction. I further release Karen Chinca, LICSW and any other individuals/agencies named from any liability arising from the release of information, provided the information is released in accordance with applicable law. I understand that this directive is subject to revocation at any time upon written request. Otherwise this consent will expire one year from the date signed. Client/Guardian Signature New Client QuestionnaireLegal Name* First Last Chosen NameGenderPreferred PronounsAgeAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone / Cell NumberOK to leave message?YesNoWork PhoneOK to leave message?YesNoEmail* OccupationWho referred you?Emergency ContactName of Emergency ContactPhoneRelationshipInsurance InformationName of your Insurance CompanySubscriber NameGroup NamePolicy NumberRelationship to SubscriberSelfChildSpouseDid you receive prior authorization?YesNoBilling InformationBilling Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Who is responsible for paying any bills incurred?MeSomeone ElseName of person responsible for bill First Last RelationshipBillpayer's Phone*Billpayer's Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code About YouWhat brings you here today?LifestyleHow many times per week do you exercise?*Not at all1-2 times3-5 times6+ timesHow much caffeine do you drink per day?*None1-2 cups3-5 cups6+ cupsHow many cigarettes do you smoke per week?*None1-5Half PackFull PackFull Pack+How many times do you drink per week?*Not at all1-2 times3-5 times6+ timesMedical HistoryHave you, or has anyone in your family ever been diagnosed with a substance abuse disorder?*YesNoPlease Explain:*Have you ever had and/or been treated for an eating disorder?*YesNoPlease Explain:*Do you have any sleep issues?*YesNoPlease Explain:*On average, how many hours do you sleep per night?When was your last physical examination?Have you ever been diagnosed with a heart condition?*YesNoPlease Explain:*Have you ever been diagnosed with a thyroid condition?*YesNoPlease Explain:*Do you have high blood pressure?*YesNoHow do you manage it?*Have you ever had a head injury?*YesNoPlease Explain:*Have you ever been the victim of a violent crime?*YesNoPlease Explain:Are you, or have you ever been in an abusive relationship?*YesNoPlease Explain:Previous hospitalizations/treatment? Please list when, where and what you were treated for:*YesNoPlease Explain:*MedicationDo you take any medications?*YesNoPlease list medications and dosage:*Who prescribes your medication?Type of PrescriberPrimary Care PhysicianPsychiatristNurse PractitionerAddress of Prescriber Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone of PrescriberDo you have any other medical concerns not noted above?*YesNoPlease Explain:Client SignaturePhoneThis field is for validation purposes and should be left unchanged. Step 1 of 5 20% Notice of Privacy PracticesPatient/Client Name*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Notice of Privacy Practices* I hereby acknowledge that I have received and have been given an opportunity to read a copy of The Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Karen Chinca at 617-739-7190.Signature*I am Signing as:*The ClientA Parent, Guardian, or Personal RepresentativeSignature of Parent, Guardian, or Personal Representative*If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.):*Receipt Refusal Patient/Client Refuses to Acknowledge Receipt Office PolicyFees and Insurance My fee is $185.00 per 45-minute individual session, $195 per 45-minute family session, and $210 for an initial 60-minute evaluation. Payment is due at the time of service, unless otherwise agreed upon. I will provide you with a detailed invoice if you choose to submit the claim to your insurance. Cancellations and Missed Appointments You will be charged the full-out-of-pocket fee of $185 per individual session and $195 per family session for missed appointments that are not cancelled at least 48 hours in advance. If your appointment is on a Monday, you must cancel your appointment by 5PM on the Friday prior to the appointment. Missed and late cancelled appointments are not billable to your insurance company. Phone Consults, Check Ins, Case Management, and Treatment Team Collaboration I am available to speak by phone between sessions if we have a scheduled time to talk. The first 15 minutes are free of charge, and after that, the rate is $45 per 15-minute increment. This includes phone check ins with clients and/or family, case management, and calls with other providers for collaborative care beyond the initial collaborative call/interaction. Emergencies and Coverage I am reachable through my office phone number, (617) 739-7190. If you are in crisis please go to a hospital emergency room or psychiatric emergency service. If you need to speak to me between appointments, but it is not an emergency, please call my voice mail and I will return your call within 24 hours of your message. When I am away and not reachable, I will have another clinician available in case of emergency, whose name and number will be on my voice mail. Confidentiality For information about privacy and confidentiality, please see the Notice of Privacy and Confidentiality Practices, which is consistent with state and federal privacy regulations.Office Policy Acknowledgement* I acknowledge that I have received a copy of the Office Policy, and agree that I am responsible for payment for missed or late cancelled visits, and for visits not covered by my health insurance. Name First Last SignatureDate Date Format: MM slash DD slash YYYY Authorization for Release of Confidential Information/RecordsI hereby authorize Karen Chinca, LICSW: to disclose to and/or obtain from:Name of Requesting or Releasing Individual or AgencyTheir Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Their Phone/FaxTheir Email The information may include: Telephone conversations regarding diagnosis and treatment Psychiatric evaluations and discharge summaries Medical records Other Please List*Acknowledgements I have carefully read and understand the above statements and do hereby expressly and voluntarily consent to disclosure of the above information and/or medical records to those persons/agencies named above. This authorization may pertain to information related to alcohol and drug use/addiction. I further release Karen Chinca, LICSW and any other individuals/agencies named from any liability arising from the release of information, provided the information is released in accordance with applicable law. I understand that this directive is subject to revocation at any time upon written request. Otherwise this consent will expire one year from the date signed. Client/Guardian Signature New Client QuestionnaireLegal Name* First Last Chosen NameGenderPreferred PronounsAgeAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone / Cell NumberOK to leave message?YesNoWork PhoneOK to leave message?YesNoEmail* OccupationWho referred you?Emergency ContactName of Emergency ContactPhoneRelationshipInsurance InformationName of your Insurance CompanySubscriber NameGroup NamePolicy NumberRelationship to SubscriberSelfChildSpouseDid you receive prior authorization?YesNoBilling InformationBilling Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Who is responsible for paying any bills incurred?MeSomeone ElseName of person responsible for bill First Last RelationshipBillpayer's Phone*Billpayer's Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code About YouWhat brings you here today?LifestyleHow many times per week do you exercise?*Not at all1-2 times3-5 times6+ timesHow much caffeine do you drink per day?*None1-2 cups3-5 cups6+ cupsHow many cigarettes do you smoke per week?*None1-5Half PackFull PackFull Pack+How many times do you drink per week?*Not at all1-2 times3-5 times6+ timesMedical HistoryHave you, or has anyone in your family ever been diagnosed with a substance abuse disorder?*YesNoPlease Explain:*Have you ever had and/or been treated for an eating disorder?*YesNoPlease Explain:*Do you have any sleep issues?*YesNoPlease Explain:*On average, how many hours do you sleep per night?When was your last physical examination?Have you ever been diagnosed with a heart condition?*YesNoPlease Explain:*Have you ever been diagnosed with a thyroid condition?*YesNoPlease Explain:*Do you have high blood pressure?*YesNoHow do you manage it?*Have you ever had a head injury?*YesNoPlease Explain:*Have you ever been the victim of a violent crime?*YesNoPlease Explain:Are you, or have you ever been in an abusive relationship?*YesNoPlease Explain:Previous hospitalizations/treatment? Please list when, where and what you were treated for:*YesNoPlease Explain:*MedicationDo you take any medications?*YesNoPlease list medications and dosage:*Who prescribes your medication?Type of PrescriberPrimary Care PhysicianPsychiatristNurse PractitionerAddress of Prescriber Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone of PrescriberDo you have any other medical concerns not noted above?*YesNoPlease Explain:Client SignatureEmailThis field is for validation purposes and should be left unchanged. Step 1 of 5 20% Notice of Privacy PracticesPatient/Client Name*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Notice of Privacy Practices* I hereby acknowledge that I have received and have been given an opportunity to read a copy of The Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Karen Chinca at 617-739-7190.Signature*I am Signing as:*The ClientA Parent, Guardian, or Personal RepresentativeSignature of Parent, Guardian, or Personal Representative*If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.):*Receipt Refusal Patient/Client Refuses to Acknowledge Receipt Office PolicyFees and Insurance My fee is $185.00 per 45-minute individual session, $195 per 45-minute family session, and $210 for an initial 60-minute evaluation. Payment is due at the time of service, unless otherwise agreed upon. I will provide you with a detailed invoice if you choose to submit the claim to your insurance. Cancellations and Missed Appointments You will be charged the full-out-of-pocket fee of $185 per individual session and $195 per family session for missed appointments that are not cancelled at least 48 hours in advance. If your appointment is on a Monday, you must cancel your appointment by 5PM on the Friday prior to the appointment. Missed and late cancelled appointments are not billable to your insurance company. Phone Consults, Check Ins, Case Management, and Treatment Team Collaboration I am available to speak by phone between sessions if we have a scheduled time to talk. The first 15 minutes are free of charge, and after that, the rate is $45 per 15-minute increment. This includes phone check ins with clients and/or family, case management, and calls with other providers for collaborative care beyond the initial collaborative call/interaction. Emergencies and Coverage I am reachable through my office phone number, (617) 739-7190. If you are in crisis please go to a hospital emergency room or psychiatric emergency service. If you need to speak to me between appointments, but it is not an emergency, please call my voice mail and I will return your call within 24 hours of your message. When I am away and not reachable, I will have another clinician available in case of emergency, whose name and number will be on my voice mail. Confidentiality For information about privacy and confidentiality, please see the Notice of Privacy and Confidentiality Practices, which is consistent with state and federal privacy regulations.Office Policy Acknowledgement* I acknowledge that I have received a copy of the Office Policy, and agree that I am responsible for payment for missed or late cancelled visits, and for visits not covered by my health insurance. Name First Last SignatureDate Date Format: MM slash DD slash YYYY Authorization for Release of Confidential Information/RecordsI hereby authorize Karen Chinca, LICSW: to disclose to and/or obtain from:Name of Requesting or Releasing Individual or AgencyTheir Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Their Phone/FaxTheir Email The information may include: Telephone conversations regarding diagnosis and treatment Psychiatric evaluations and discharge summaries Medical records Other Please List*Acknowledgements I have carefully read and understand the above statements and do hereby expressly and voluntarily consent to disclosure of the above information and/or medical records to those persons/agencies named above. This authorization may pertain to information related to alcohol and drug use/addiction. I further release Karen Chinca, LICSW and any other individuals/agencies named from any liability arising from the release of information, provided the information is released in accordance with applicable law. I understand that this directive is subject to revocation at any time upon written request. Otherwise this consent will expire one year from the date signed. Client/Guardian Signature New Client QuestionnaireLegal Name* First Last Chosen NameGenderPreferred PronounsAgeAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone / Cell NumberOK to leave message?YesNoWork PhoneOK to leave message?YesNoEmail* OccupationWho referred you?Emergency ContactName of Emergency ContactPhoneRelationshipInsurance InformationName of your Insurance CompanySubscriber NameGroup NamePolicy NumberRelationship to SubscriberSelfChildSpouseDid you receive prior authorization?YesNoBilling InformationBilling Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Who is responsible for paying any bills incurred?MeSomeone ElseName of person responsible for bill First Last RelationshipBillpayer's Phone*Billpayer's Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code About YouWhat brings you here today?LifestyleHow many times per week do you exercise?*Not at all1-2 times3-5 times6+ timesHow much caffeine do you drink per day?*None1-2 cups3-5 cups6+ cupsHow many cigarettes do you smoke per week?*None1-5Half PackFull PackFull Pack+How many times do you drink per week?*Not at all1-2 times3-5 times6+ timesMedical HistoryHave you, or has anyone in your family ever been diagnosed with a substance abuse disorder?*YesNoPlease Explain:*Have you ever had and/or been treated for an eating disorder?*YesNoPlease Explain:*Do you have any sleep issues?*YesNoPlease Explain:*On average, how many hours do you sleep per night?When was your last physical examination?Have you ever been diagnosed with a heart condition?*YesNoPlease Explain:*Have you ever been diagnosed with a thyroid condition?*YesNoPlease Explain:*Do you have high blood pressure?*YesNoHow do you manage it?*Have you ever had a head injury?*YesNoPlease Explain:*Have you ever been the victim of a violent crime?*YesNoPlease Explain:Are you, or have you ever been in an abusive relationship?*YesNoPlease Explain:Previous hospitalizations/treatment? Please list when, where and what you were treated for:*YesNoPlease Explain:*MedicationDo you take any medications?*YesNoPlease list medications and dosage:*Who prescribes your medication?Type of PrescriberPrimary Care PhysicianPsychiatristNurse PractitionerAddress of Prescriber Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone of PrescriberDo you have any other medical concerns not noted above?*YesNoPlease Explain:Client SignaturePhoneThis field is for validation purposes and should be left unchanged.
