Enrollment Form Please fill out this form and our team will get in contact with you to schedule an appointment Medical and Psychiatric History FormMedical and Psychiatric History FormFirst NameLast NameDate of BirthEmailPhone/MobilePrimary CareTherapist/CounselorTherapist’s PhonePreferred PharmacyWhat are the problem(s) for which you are seeking help?What are your treatment goals?Current SymptomsPlease check the ones that apply to you.Current Symptoms Checklist: Depressive mood Unable to enjoy activities Sleep disturbance Loss of Interest Change in Appetite Concentration/Forgetfulness Racing thoughts Impulsivity Increase Risky Behavior Excessive energy Increased Irritability Crying spells Excessive Worry Anxiety attacks Suicidal thoughts Poor energy HallucinationsOtherOtherOtherOtherMedical HistoryMedical InformationCurrent medical problems:Past Medical Problem, nonpsychiatric hospitalizations or surgeriesAlergiesCurrent Weight:Height:Have you ever had an EKG? Yes NoIf yes, when?Was the EKG Normal Abnormal UnknownList all prescription medications and how often you take them: (If none, write none)Medication NameMedication NameMedication NameMedication NameMedication NameTotal DoseTotal DoseTotal DoseTotal DoseTotal DoseEstimated Start DateEstimated Start DateEstimated Start DateEstimated Start DateEstimated Start DateCurrent over the counter medications or supplements:Medication NameMedication NameMedication NameMedication NameMedication NameTotal DoseTotal DoseTotal DoseTotal DoseTotal DoseEstimated Start DateEstimated Start DateEstimated Start DateEstimated Start DateEstimated Start DatePersonal/Family Medical HistoryPlease put a check mark if the medical history applies to you or a family member:YouFamilyAnemiaLiver DiseaseKidney Disease Heart Problems High Blood Pressure Asthma/Respiratory ProblemsStomach or Intestinal ProblemsCancer Fibromyalgia Seizure/EpilepsyChronic PainHigh CholesterolHead Trauma/ConcussionDiabetes OtherText InputText InputText InputText InputText InputText InputText InputText InputText InputText InputText InputText InputText InputText InputText InputWhen 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 HistoryOutpatient TreatmentDate / TimeReasonProvider/OrganizationPartial Hospitalization ProgramDate / TimeReasonProvider/OrganizationRehabilitation/detoxDate / TimeReasonProvider/OrganizationInpatientDate / TimeReasonProvider/OrganizationOtherWhatDate / TimeReasonProvider/OrganizationPast Medication Trials: Put a check mark on the medication you have tried in the past AntidepressantsAntidepressantsProzac (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 TrintellixTrazodoneOtherAntipsychoticAntipsychoticSeroquel (Quetiapine) Zyprexa (Olanzapine) Geodon (Ziprasidone) Abilify (Aripiprazole)Clozaril (Clozapine) Haldol (Haloperidol) Prolixin (Fluphenazine) Risperdal (Risperidone) Latuda (Lurasidone) Vraylar (Cariprazine) Invega (Paliperidone)OtherAnti-AnxietyAnti-AnxietyXanax (Alprazolam) Ativan (Lorazepam)Klonopin (Clonazepam)Valium (Diazepam)Buspar (Buspirone) OtherMood Stabilizers Mood Stabilizers Tegretol (carbamazepine) LithiumDepakote (Valproate)Lamictal (Lamotrigine) Topamax (Topiramate)Neurontin (gabapentin)Trileptal (Oxcarbazepine) OtherADHD MedicationADHD MedicationAdderall (amphetamine salt)Concerta (Methylphenidate)Ritalin (Methylphenidate) Strattera (Atomoxetine)Vyvanse Guanfacine (Intuniv)Clonidine (Catapress) OtherSedative/HypnoticSedative/HypnoticAmbien (Zolpidem)Sonata (Zaleplon) Rozerem (Ramelteon) Restoril (Temazepam)Lunesta (Eszopiclone)OtherSubstance Use: AlcoholHow oftenHow muchLast usedNicotineHow oftenHow muchLast usedMarijuanaHow oftenHow muchLast usedHeroineHow oftenHow muchLast usedCocaineHow oftenHow muchLast usedOtherWhatHow oftenHow muchLast usedFamily Psychiatric History: Has anyone in your family has been diagnosed or treated for:ProblemYesNoBipolar Disorder Schizophrenia Depression PTSDAlcohol use disorderDrugs ADHD ViolenceOtherIf yes, who?If yes, who?If yes, who?If yes, who?If yes, who?If yes, who?If yes, who?If yes, who?If yes, who?I attest that all the information on this form is accurate to the best of my knowledge. First NameLast NamePatientSignature of patient, parent or guardian Sign Here Submit Form
