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of Birth |
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Male Female |
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Street
City
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State
Zip
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Insurance Information |
Full Name of Insured |
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Social Security # of Insured |
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Insured's Date of Birth |
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(if different)
Street 1
Street 2
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City
State
Zip
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Name of Insurance carrier for Mental/Behavioral
Health Benefits |
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Complete Address for Mental/Behavioral Health claims |
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Phone Number for Mental/Behavioral Health claims |
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Insurance ID number |
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Co-pay amount (if known) |
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Deductible amount (if known) |
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Immediate Family Members |
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Yes No |
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Medical History |
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Yes No |
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Phone number:
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Yes No (If "No," please state reason for refusal
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I have reviewed the Practice's Notice and Privacy Practices and understand that my protected health information may be used by the Practice as described in the notice. |
Yes No
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Food or drug allergies?
If yes, nature of reaction: |
Yes No
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Family History: (psychiatric history, substance abuse history, suicide and homicide of family members, history of abuse) |
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Psychosocial History: (social/cultural/spiritual factors and support, education and job history, legal history, sexual orientation, utilization of community resources, significant childhood events)
Children/Adolescents: include developmental history and educational history: |
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Marriage/Family: (marital history, including current/prior marriages/significant relationships; names/relationships with children |
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Interests & Activities |
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Strengths & Weaknesses: |
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