EMERGENCY CONTACT

Emergency Contact Name

Contact phone number

Address

Patient's Relation

PHARMACY DETAILS

Pharmacy details- Name and Address

Allergies

INSURENCE CHECK

Insurance check box *

INSURENCE 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 Agreed and Acknowledge to Treatment Consent and Financial Policy

I Agreed and Acknowledge to HIPAA Notice of Privacy Practices

I Agreed 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 PSYCHIATIC 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 psychiatrst Name

Any Psychiatric Hospitlization?

Current Therapist/Counselor

Past suicidal ideation/ attempt / plan

Medications for mental health reason

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

No

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

Yes

No

What is your highest educational level or degree attained?

Do you have a history of being abused emotionally, sexually, physically or by neglect?

Yes

No

Legal History: Have you been arrested?

Yes

No

How many days a week do you get exercise?

Do you follow any particular diet ?

What kind of exercise do you do?

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 *