Medication Appointment - Adult

First Name *

Middle Initial

Last Name *

SSN *

Date of birth * +

Age *

Gender *

Male

Female

Street Address *

Address Line 2

City *

State *

Zip Code *

What is the preferred number to reach you at? *

Phone Number *

Would you like to add another contact number? *

Yes

No

Phone Number

Best time to call *

7:30 - 9:00

9:00 - 12:00

12:00 - 3:00

3:00 - 5:00

Email Address *

We provide courtesy appointment reminders. If you would like to receive a reminder, please let us know which method you prefer or you may opt out. Standard messaging rates may apply for texts. Confirmation reminders are a courtesy only. It is still your responsibility to make all your appointment. *

Text

Call

I opt out

Cell Carrier? *

Best time to call *

7:30 - 9:00

9:00 - 12:00

12:00 - 3:00

3:00 - 5:00

Email Address *

Emergency contact information

	Name	Phone number	Relationship
1	Name	Phone number	Relationship
2	Name	Phone number	Relationship

Responsible Financial Party

We require a credit card to be placed on file. Cards are securely filed and will be used only for payment of co-pays, co-insurance, payments for service and no-show fees. Credit card information must be entered even if you are not the responsible party.

TRICARE Prime and Active Duty Service Member will not be charged a co-pay but must still put card information for any no-show fees.

No Show / Late Cancellation Policy

By checking this box, you acknowledge that you have read the no show / late cancellation policy. *

Agree

Is financial responsibility someone other than the patient? *

Yes

No

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

Security Code *

By checking the box below, you agree that we may charge the card provided for the amount owed the day after it is reflected on the account. *

I agree

First Name *

Last Name *

SSN *

Street Address

Address Line 2

City

State

Zip Code

Home Phone Number

Work Phone Number

Cell Phone Number *

Email address *

Referral Information

Who referred you to Family Care Center? *

Name and number of your primary care physician if know?

Name and number of therapist if know?

Presenting Problem

What are the problems or concerns you are having? *

When did the problem begin and for how long has it gone on? *

Treatment History

Prior OUTPATIENT psychotherapy? *

Yes

No

How many times?

Dates if known.

+-

Diagnosis *

Therapist information

	Name	City, State	Phone number
1	Name	City, State	Phone number
2	Name	City, State	Phone number
3	Name	City, State	Phone number
4	Name	City, State	Phone number
5	Name	City, State	Phone number

Treatment Modality (check all that apply)

Which, if any, were beneficial?

Has any family member had any mental health treatment? *

Yes

No

Who and for what reason or diagnosis and where they given any medications? (list all here)

Prior INPATIENT treatment for psychiatric, emotional, or substance use disorder? *

Yes

No

How many times?

Dates if known.

+-

Diagnosis *

Inpatient facility information

	Name	City, State	Phone number
1	Name	City, State	Phone number
2	Name	City, State	Phone number
3	Name	City, State	Phone number
4	Name	City, State	Phone number
5	Name	City, State	Phone number

Treatment Modality (check all that apply)

Which, if any, were beneficial?

Prior or current psychotropic medication use? *

Yes

No

List all psychotropic medications below.

	Medications	Dosage	Side Effects	Beneificial
Medication #1	Medications	Dosage	Side Effects	Beneificial
Medication #2	Medications	Dosage	Side Effects	Beneificial
Medication #3	Medications	Dosage	Side Effects	Beneificial
Medication #4	Medications	Dosage	Side Effects	Beneificial
Medication #5	Medications	Dosage	Side Effects	Beneificial
Medication #6	Medications	Dosage	Side Effects	Beneificial

Family History

Parents current marital status:

Married

Divorced

Seperated

Deceased

Present during your childhood:

	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A
Mother	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A
Father	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A
Stepmother	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A
Stepfather	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A
Brother(s)	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A
Sister(s)	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A

Anybody else not listed above?

Describe childhood family experience: (check all that apply)

Outstanding home environment

Normal home environment

Chaotic home environment

Witnessed physical/verbal/sexual abuse towards others

Experienced physical/verbal/sexual abuse from others

Age of emancipation and circumstances if applicable: 🛈

Any other special circumstances in childhood that we should know about?

Current Marital Status:

Number of Marriages for Self?

Number of Marriages for Partner?

Intimate Relationships:

Never been in a serious relationship

Not currently in a relationship

Currently in a serious relationship

Relationship Satisfaction:

List all persons currently living in your household.

	Name	Age	M / F	Relationship to patient
1	Name	Age	M / F	Relationship to patient
2	Name	Age	M / F	Relationship to patient
3	Name	Age	M / F	Relationship to patient
4	Name	Age	M / F	Relationship to patient
5	Name	Age	M / F	Relationship to patient

List all children currently NOT living in same household as you.

	Name	Age	M / F	Relationship to patient
1	Name	Age	M / F	Relationship to patient
2	Name	Age	M / F	Relationship to patient
3	Name	Age	M / F	Relationship to patient
4	Name	Age	M / F	Relationship to patient
5	Name	Age	M / F	Relationship to patient

Frequency of visitation of above.

Describe any past or current significant issues in intimate relationships.

Describe any past or current significant issues in other immediate family relationships.

Medical History (check all that apply)

Describe your current health. *

Good

Fair

Poor

List any known allergies or put NKA. *

Is there a history of the following in the family? *

Any other medications being taken not previously mentioned? *

Yes

No

List any medications currently being taken.

	Medication	Dosage	Reason
1	Medication	Dosage	Reason
2	Medication	Dosage	Reason
3	Medication	Dosage	Reason
4	Medication	Dosage	Reason
5	Medication	Dosage	Reason

Any serious hospitalizations or accidents? *

Yes

No

Describe.

	Date	Age	Reason
1	Date	Age	Reason
2	Date	Age	Reason
3	Date	Age	Reason
4	Date	Age	Reason

Any abnormal labs? *

Yes

No

Describe.

	Date	Result
1	Date	Result
2	Date	Result
3	Date	Result
4	Date	Result

Name and phone number of psychiatrist if known.

Substance Use History

Substances Used:

Alcohol *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Amphetamines/speed *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Barbiturates *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Cocaine *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Crack cocaine *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Hallucinogens (e.g., LSD) *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Inhalants (e.g., glue, gas) *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Marijuana or hashish *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Nicotine/cigarettes *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

PCP *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Prescription drugs *

Yes

No

Which drug if yes? Which drug if yes?

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Others not listed *

Yes

No

Which drug if yes? Which drug if yes?

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Consequences of substance use

Have you ever had treatment for substance abuse *

Yes

No

Substance use treatment history

	Age	Successful
Outpatient	Age	Successful
Inpatient	Age	Successful
12-step program	Age	Successful
Stopped on own	Age	Successful
Other	Age	Successful

Family substance abuse history *

	Check all that apply
	yes	no	N/A
Father	yes	no	N/A
Mother	yes	no	N/A
Grandparents(s)	yes	no	N/A
Sibling(s)	yes	no	N/A
Step-parent / live-in	yes	no	N/A
Uncle(s) / Aunt(s)	yes	no	N/A
Spouse / significant other	yes	no	N/A
Children	yes	no	N/A
Other	yes	no	N/A

Socio-Economic History (check all that apply)

Housing situation: *

Employment: *

Financial Situation: *

Social support system: *

Military history: *

Explain

Number of deployments.

Deployment dates and location.

+-

Military occupation.

Legal history *

	Check all that apply
	yes	no
Current or past legal problems	yes	no
on parole / probation	yes	no
Arrest(s) not substance use related	yes	no
Arrest(s) substance use related	yes	no
Court ordered for this treatment	yes	no
Jail / prison	yes	no

If applicable, how many times have you been to jail / prison and what is the total time served?

If applicable, describe last legal difficulty.

Activities

	Yes	No
Currently active in community / recreational activities	Yes	No
Formerly active in community / recreational activities	Yes	No
Currently engage in hobbies	Yes	No
Currently engage in spiritual activities	Yes	No

Sexual Orientation *

Currently sexual active?

Yes

No

Sexually satisfied?

Yes

No

If applicable, age of first sexual experience

If applicable, age of first pregnancy / fatherhood

History of promiscuity? *

Yes

No

How long did it go on?

	Youngest age	Oldest age
Age	Youngest age	Oldest age

History of unsafe sex? *

Yes

No

How long did it go on?

	Youngest age	Oldest age
Age	Youngest age	Oldest age

Ethnicity

Religion

Describe any cultural issues that contribute to current problem:

Describe if answering "Yes" to any of the above.

Notices

Patient Grievances

Patient Rights

Non-discrimination Notice

Notice of Privacy Practices

By checking this box, you acknowledge that you have read the notices above. *

Agree

Acknowledgement and Signature

By signing this form, you agree that you are willing to be seen by a provider at the Family Care Center and will become a client of this clinic upon submission of this form. Clients are responsible for all payments at time of service. Clients who do not show up for this initial appointment or any subsequent follow-up appointments are subject to a $50 no-show fee which must be paid prior to any further appointments being made. Two or more no-shows for an initial appointment can result in you not being accepted as a client. *

clear

Cognitive Processing Therapy	Cognitive Behavioral Therapy
EMDR	Prolonged Exposure
Dialectical Behavioral Therapy	Not Known
Other Other

Cognitive Processing Therapy	Cognitive Behavioral Therapy
EMDR	Prolonged Exposure
Dialectical Behavioral Therapy	Not Known
Other Other

Tuberculosis	Birth defects	Emotional problems
Thyroid problems	Cancer	Mental retardation
Heart disease	High blood pressure	Alcoholism
Drug abuse	Diabetes	Alzheimer's disease / dementia
Stroke	Other Other

Hangovers	Blackouts	Tolerance changes	Suicidal ideations
Withdrawal symptoms	Sleep disturbance	Binges	Seizures
Medical conditions	Assaults	Job loss	Arrests
Overdose	Loss of control	Relationship conflicts	Other Other