MES

MENTAL HEALTH INTAKE FORM

Our patient intake questionnaire helps us get to know you better and build a treatment based on your individual needs. Start your recovery journey with us. Kindly fill out the form with the correct information.

NAME

First Name

Last Name

ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

CELL PHONE

Country

(###)

###

####

EMAIL ADDRESS

DATE OF BIRTH

YYYY

PRONOUNS

SEX

GENDER

ALTERNATIVE PHONE

(###)

###

####

COUNTY

SOCIAL SECURITY NUMBER

RACE

MARITAL STATUS

REFERRED BY

POA / GUARDIAN

First Name

Last Name

ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

CELL PHONE

Country

(###)

###

####

ALTERNATIVE PHONE

Country

(###)

###

####

COUNTY

CLIENT'S RELATIONSHIP

EMERGENCY CONTACT

First Name

Last Name

ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

CELL PHONE

Country

(###)

###

####

CLIENT'S RELATIONSHIP

EMPLOYMENT

COMPANY NAME

ALLERGIES

HEIGHT (FOR AGES 17 AND UNDER)

WEIGHT (FOR AGES 17 AND UNDER)

PRIMARY CARE PHYSICIAN

First Name

Last Name

OFFICE PHONE

Country

(###)

###

####

ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

LAST PRIMARY CARE VISIT

MEDICATION

PHARMACY PHONE NUMBER

Country

(###)

###

####

NAME OF MEDICATION

DOSAGE

PRESCRIBING PHYSICIAN

NAME OF MEDICATION

DOSAGE

PRESCRIBING PHYSICIAN

NAME OF MEDICATION

DOSAGE

PRESCRIBING PHYSICIAN

TYPE OF INSURANCE

INSURANCE CARD NUMBER

DRIVER'S LICENSE NUMBER