Enrollment Form

Please fill out this form and our team will get in contact with you to schedule an appointment

Medical and Psychiatric History Form

First Name

Last Name

Date of Birth

Phone/Mobile

Primary Care

Therapist/Counselor

Therapist’s Phone

Preferred Pharmacy

What are the problem(s) for which you are seeking help?

What are your treatment goals?

Current Symptoms

Please check the ones that apply to you.

Medical History

Medical Information

Current medical problems:

Past Medical Problem, nonpsychiatric hospitalizations or surgeries

Alergies

Current Weight:

Height:

List all prescription medications and how often you take them: (If none, write none)

Medication Name

Total Dose

Estimated Start Date

Current over the counter medications or supplements:

Medication Name

Total Dose

Estimated Start Date

Personal/Family Medical History

Please put a check mark if the medical history applies to you or a family member:

	You	Family
Anemia
Liver Disease
Kidney Disease
Heart Problems
High Blood Pressure
Asthma/Respiratory Problems
Stomach or Intestinal Problems
Cancer
Fibromyalgia
Seizure/Epilepsy
Chronic Pain
High Cholesterol
Head Trauma/Concussion
Diabetes

Other

Text Input

When your mother was pregnant with you, were there any complications during the pregnancy, birth or developmental in the first few years of life:

Past Psychiatric History

Outpatient Treatment

Date / Time

Reason

Provider/Organization

Partial Hospitalization Program

Date / Time

Reason

Provider/Organization

Rehabilitation/detox

Date / Time

Reason

Provider/Organization

Inpatient

Date / Time

Reason

Provider/Organization

Other

What

Date / Time

Reason

Provider/Organization

Past Medication Trials: Put a check mark on the medication you have tried in the past

Antidepressants

	Antidepressants
Prozac (Fluoxetine)
Zoloft (sertraline)
Luvox (Fluvoxamine)
Paxil (Paroxetine)
Celexa (Citalopram)
Lexapro (Escitalopram)
Effexor (Venlafaxine)
Cymbalta (Duloxetine)
Wellbutrin (Bupropion)
Remeron (Mirtazapine)
Anafranil (Clomipramine)
Pamelor (Nortriptyline)
Elavil (Amitriptyline)
Viibrid
Trintellix
Trazodone

Other

Antipsychotic

	Antipsychotic
Seroquel (Quetiapine)
Zyprexa (Olanzapine)
Geodon (Ziprasidone)
Abilify (Aripiprazole)
Clozaril (Clozapine)
Haldol (Haloperidol)
Prolixin (Fluphenazine)
Risperdal (Risperidone)
Latuda (Lurasidone)
Vraylar (Cariprazine)
Invega (Paliperidone)

Other

	Anti-Anxiety
Xanax (Alprazolam)
Ativan (Lorazepam)
Klonopin (Clonazepam)
Valium (Diazepam)
Buspar (Buspirone)

	Mood Stabilizers
Tegretol (carbamazepine)
Lithium
Depakote (Valproate)
Lamictal (Lamotrigine)
Topamax (Topiramate)
Neurontin (gabapentin)
Trileptal (Oxcarbazepine)

	ADHD Medication
Adderall (amphetamine salt)
Concerta (Methylphenidate)
Ritalin (Methylphenidate)
Strattera (Atomoxetine)
Vyvanse
Guanfacine (Intuniv)
Clonidine (Catapress)

	Sedative/Hypnotic
Ambien (Zolpidem)
Sonata (Zaleplon)
Rozerem (Ramelteon)
Restoril (Temazepam)
Lunesta (Eszopiclone)

Substance Use:

Alcohol

How often

How much

Last used

Nicotine

How often

How much

Last used

Marijuana

How often

How much

Last used

Heroine

How often

How much

Last used

Cocaine

How often

How much

Last used

Other

What

How often

How much

Last used

Family Psychiatric History:

Has anyone in your family has been diagnosed or treated for:

If yes, who?

I attest that all the information on this form is accurate to the best of my knowledge.

First Name

Last Name

Patient

Signature of patient, parent or guardian

Sign Here

	Yes	No
Bipolar Disorder
Schizophrenia
Depression
PTSD
Alcohol use disorder
Drugs
ADHD
Violence