NEW PATIENT DEMOGRAPHIC INFORMATION

Date of Birth

Address

Zip code

EMERGENCY CONTACT

Emergency Contact Name

Contact phone number

Address

Patient's Relation

PHARMACY DETAILS

Pharmacy details- Name and Address

Allergies

INSURANCE CHECK

Insurance check box *

INSURANCE DETAIL

Active Primary Insurance

Policy ID

Group ID

Policy Holder's Name

Relation to Patient

Details of any secondary insurance

Please upload picture of your insurance card Insurance card Front And back

CLINIC POLICIES

*Our office Does not do FMLA

**48 hours( Excluding Weekends) cancellation is required to avoid No Show fee

I Agree and Acknowledge to Treatment Consent and Financial Policy

I Agree and Acknowledge to HIPAA Notice of Privacy Practices

I Agree and Acknowledge to Informed Consent For Telepsychiatry

I hereby acknowledge that the Clinic Policies have been made available to me for review. I am aware that the policies for this practice may change from time to time and that the current copy of the policy is always available upon request from the GHHP staff. I understand that the clinic is not responsible for providing me with the updated policy and it is my responsibility to request GHHP staff in writing. As you are filling this form electronically, typing your name in this field will be equivalent to signing your name on a paper document. *

Clear

MEDICAL AND PSYCHIATRIC HISTORY

What are the problem(s) for which you are seeking help

1
2
3

Past Psychiatric History. Ever been diagnosed or treated with any mental health illness?

Previous Psychiatrist Name

Any Psychiatric Hospitlization?

Current Therapist/Counselor

Past suicidal ideation/ attempt / plan

Medications given for mental health illness

Medical and Surgical History:

Current Medications for Non-Psychiatric conditions:

Family Medical History ( if any)

Family Psychiatric History

Primary Care Physician with phone number

Are you planning to get pregnant in the near future?

Yes

Are you currently pregnant or do you think you might be pregnant?

Yes

What is your highest educational level or degree attained?

Do you have a history of neglect, physical, sexual or emotional abuse?

Yes

Legal History: Have you ever been arrested?

Yes

How many days a week do you exercise?

What kind of exercise do you do?

Do you follow any particular diet?

PHQ-9

Over the last 2 weeks, how often have you been bothered by any of the following problems? Please Select your answers.

Little interest or pleasure in doing things *

Feeling down, depressed, or hopeless. *

Trouble falling or staying asleep, or sleeping too much. *

Feeling tired or having little energy. *

Trouble concentrating on things, such as reading the newspaper or watching television. *

Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual. *

Thoughts that you would be better off dead, or of hurting yourself in some way. *

Poor appetite or overeating. *

Feeling bad about yourself – or that you are a failure or have let yourself or your family down.

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Difficulty Level *

GAD 7

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Feeling nervous, anxious, or on edge *

Worrying too much about different things. *

Trouble relaxing. *

Not being able to stop or control worrying. *

Being so restless that it’s hard to sit still. *

Becoming easily annoyed or irritable *

Feeling afraid as if something awful might happen *

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Difficulty Level *