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Fill Out Patient Form

Core Horizons Behavioral Health New Patient Psychiatric Intake Form.

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Patient Information

Full Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Gender(Required)

Male

Female

Other

Phone Number(Required)

Email Address

Home Address(Required)

Street Address City ZIP / Postal Code

Emergency Contact Name & Relationship(Required)

Emergency Contact Phone Number(Required)

Preferred Pharmacy & Location(Required)

Street Address

Insurance Information

Primary Insurance Company(Required)

Member ID Number(Required)

Group Number(Required)

Policy Holder Name(Required)

Policy Holder Date of Birth(Required)

MM slash DD slash YYYY

Relationship to Policy Holder(Required)

Secondary Insurance (if applicable)

Reason for Visit

What concerns brought you in today?(Required)

How long have you been experiencing these concerns?(Required)

Current Symptoms (check all that apply):(Required)

Anxiety

Depression

Mood Swings

Panic Attacks

ADHD Symptoms

Sleep Problems

Trauma/PTSD

Irritability

Hallucinations

Racing Thoughts

Poor Concentration

Appetite Changes

Substance Use

Suicidal Thoughts

Self-Harm

Aggression

Social Withdrawal

Autism Concerns

Other Symptoms

Current Diagnoses

Have you ever been diagnosed with a mental health condition?(Required)

Current/Past Diagnoses(Required)

Current Medications

Medication Name | Dose | Frequency | Prescribing Provider(Required)

Are you taking medications as prescribed?(Required)

Yes

No

Any medication side effects?

Medical History

Primary Care Provider(Required)

Current Medical Conditions(Required)

Past Medical History(Required)

Past Surgeries/Procedures(Required)

History of Seizures, Head Injuries, or Loss of Consciousness?(Required)

Psychiatric History

Previous Psychiatrist/Therapist(Required)

Previous Mental Health Treatment(Required)

Any past psychiatric hospitalizations?(Required)

Yes

No

If yes, explain(Required)

History of self-harm or suicide attempts?(Required)

Yes

No

If yes, explain(Required)

Current suicidal thoughts?

Yes

No

Current homicidal thoughts?(Required)

Yes

No

History of hallucinations or psychosis?

Yes

No

Substance Use History

Do you use tobacco/nicotine?(Required)

Yes

No

Alcohol Use(Required)

Cannabis Use(Required)

Other Substance Use(Required)

Any history of substance abuse treatment?(Required)

Yes

No

Allergies

Medication Allergies:(Required)

Food Allergies(Required)

Environmental Allergies(Required)

Reaction(s)(Required)

Family & Social History

Who lives in the home with you?(Required)

Relationship Status(Required)

Occupation/School(Required)

Any family history of mental illness?(Required)

Any family history of substance abuse?(Required)

Any legal issues or trauma history?(Required)

Sleep, Appetite & Functioning

Average hours of sleep per night(Required)

Any sleep concerns?(Required)

Appetite Changes?(Required)

Energy Level(Required)

How are symptoms affecting daily functioning?(Required)

Consent & Signature

Terms and Conditions(Required)

I certify that the information provided is accurate to the best of my knowledge.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

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