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609 583 4969
[email protected]
1901 North Olden Avenue Ext, Suite 11A, Ewing, NJ 08618
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609 583 4969
[email protected]
1901 North Olden Avenue Ext, Suite 11A, Ewing, NJ 08618
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Initial Evaluation Form
Fill out and submit the form below with the correct information.
DATE
MM slash DD slash YYYY
SOCIAL SECURITY NUMBER
Name
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
HOME PHONE
CELL PHONE
WORK PHONE
EXT
OK TO LEAVE A MESSAGE ON MACHINE AT HOME?
Yes
No
OK TO LEAVE A MESSAGE WITH A FAMILY MEMBER?
Yes
No
OK TO LEAVE A MESSAGE AT WORK (VOICEMAIL)?
Yes
No
OK TO LEAVE A MESSAGE ON CELL PHONE?
Yes
No
Email
DATE OF BIRTH
MM slash DD slash YYYY
AGE
GUARDIANSHIP (ADULTS WHEN APPLICABLE)
ROLE IN FAMILY UNIT CIRCLE ONE
Mother
Daughter
Son
Husband
Other
OK TO LEAVE A MESSAGE ON CELL PHONE?
Yes
No
MARITAL STATUS
Single
Married
Divorced
Separated
EMPLOYER OR SCHOOL (IF APPLICABLE)
EMPLOYMENT STATUS
EMPLOYMENT STATUS
EMPLOYMENT STATUS
EMERGENCY CONTACT
Name
First
Last
RELATIONSHIP TO PATIENT
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
I authorize Healthy Mind to contact the above-named person in case of an emergency.
I authorize
REFERRAL SOURCE
Insurance
Internet
Friend
THERAPIST
Mental Health Therapist/MD
Facility
Name
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
PHARMACY INFORMATION
PHARMACY NAME
ADDRESS
Phone
LIST ALL PSYCHIATRIC MEDICATIONS THAT YOU ARE CURRENTLY TAKING
LIST ALL PSYCHIATRIC MEDICATIONS THAT YOU ARE CURRENTLY TAKING
NAME OF MEDICATION
DOSAGE/FREQUENCY
Add
Remove
Name
First
Last
PATIENT-PROVIDER AUTHORIZATIONS AND AGREEMENTS.
Authorizations and Agreements with Healthy Mind. Please read carefully and sign. The paragraphs below contain several agreements.
PATIENTS NAME
Date
MM slash DD slash YYYY
FINANCIAL RESPONSIBILITY
I understand and agree that I am responsible for the fees to Healthy Mind before services are rendered.
I understand and agree
PRIMARY CARE PHYSICIAN CONTACT AUTHORIZATION
PRIMARY CARE PHYSICIAN'S NAME
ADDRESS
Phone
FAX NUMBER
I, (Print Name)
hereby authorize Healthy Mind
PLEASE CHECK ONE
To release any applicable mental health information to my primary care physician (PCP) above
To release any applicable substance abuse information to my PCP named above
To release only medical information to my PCP named above
Not to release any information to my PCP named above
I DO NOT HAVE A PCP AT THIS TIME
I may revoke this authorization at any time except to the extent that action has been taken in reliance upon it. If I do not revoke this authorization, it will expire one (1) year after I have terminated treatment.
I agree
PATIENT OR GUARDIAN NAME
Date
MM slash DD slash YYYY
INFORMED CONSENT FOR TREATMENT
I, (Print Name)
(name of patient), agree and consent to participate in behavioral healthcare services offered and provided by Healthy Mind, a behavioral health care provider. I understand that I am consenting and agreeing only to those services that the above-named provider is qualified to provide within: (1) the scope of the provider's license, certification, and training; or (2) within scope of license, certification, and training of the behavioral health care provider directly supervising the services
PATIENT NAME
Full Name
Date
MM slash DD slash YYYY
RELATIONSHIP TO PATIENT (IF APPLICABLE)
Signature
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