Supplemental Intake Form:

First Name: Last Name: Home Address: Phone Number: Sex Assigned at Birth: Primary Care Provider: Therapist: Date of Birth: Have they ever had a suicide attempt or been psychiatrically hospitalized? If so, please type in which hospital and date:

MEDICAL HISTORY

Please list all Psychiatric Hospitalizations if any: Please list all surgical/Medical history if any:

Do you now or ever had the following conditions? Please select all that apply.

Any Other Medical Conditions that have been diagnosed? Do you have any medication allergies? List all current medications, including over the counter medications/supplements: List all past psychiatric medication trials: Do you have a substance abuse history? If so, when/what? Are you seeking treatment from a specific provider and if so, type their name here Highest Level of Education: Occupation: Do you have children? If so, how many and ages?

I am hereby signing below that all above answers are truthful based on my current knowledge.

Patient Name: Electronic Signature: Date: You agree your electronic signature is the legal equivalent of your manual signature on this agreement.

Supplemental Intake Form

Supplemental Intake Form:

MEDICAL HISTORY

Do you now or ever had the following conditions? Please select all that apply.

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