Optimum Behavioral Health

& Wellness, LLC.

New Patient Intake Form

Patient Information

• Full Name: _____________________________________________________

• Date of Birth: _____________m/d/yr

• Age: ______

• Gender: ☐ Male ☐ Female ☐Other

• Address: _______________________________________________________

• City/State/Zip: __________________________________________________

• Phone Number: _____________________ ☐Cell ☐Home

• Email Address: ______________________________________

• Preferred Method of Contact: ☐ Phone ☐ Email ☐ Text

• Emergency Contact (Name/Phone/Relationship):

_______________________________________________________________

• How did you hear about us? ☐Social Media ☐Internet search ☐Friend ☐Family

Insurance Information

• Primary Insurance: _________________________________

• Policy/Member ID: _________________________________

• Group Number: ____________________________________

• Policy Holder (if not patient): _________________________

• Relationship to Patient: ______________________________

Primary Care Provider

• Name: ____________________________________________

• Phone: ____________________________________________

• Address: ___________________________________________

Presenting Concerns

1. What are the main reasons you are seeking counseling/medication management?

________________________________________________________________

2. When did these concerns begin? ______________________________________

3. Have you received counseling/mental health treatment before? ☐ Yes ☐ No.

By whom: ☐Psychiatrist ☐Psychologist ☐LCSW ☐LPC ☐NP

If yes, where/when? ________________________________________________

Mental Health & Medical History

• Have you ever been diagnosed with a mental health condition? ☐ Yes ☐ No

If yes, please specify: ________________________________________________

• Have you ever been hospitalized for psychiatric reasons? ☐ Yes ☐ No

If yes, when/where: __________________________________________________

• Do you currently take psychiatric medication? ☐ Yes ☐ No

If yes, please list medication ___________________________________________

• Do you have any medical conditions we should be aware of? ☐ Yes ☐ No

If yes, explain: ______________________________________________________

• Current medications (non-psychiatric):

• Allergies: __________________________________________________________

Substance Use History

• Do you currently use alcohol? ☐ Yes ☐ No

If yes, how often/how much? _________________________

• Do you currently use recreational drugs? ☐ Yes ☐ No

If yes, type and frequency: __________________________

• Do you use tobacco or vape? ☐ Yes ☐ No

Safety & Risk

• Have you ever had thoughts of harming yourself? ☐ Yes ☐ No

If yes, when? _____________________________________

• Have you ever attempted suicide? ☐ Yes ☐ No

If yes, when/how? _________________________________

• Do you currently have thoughts of self-harm or suicide? ☐ Yes ☐ No

• Have you ever had thoughts of harming others? ☐ Yes ☐ No

Family & Social History

• Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Widowed ☐ Other

• Children: ☐ Yes ☐ No If yes, how many? ____________

• Current Living Situation: ☐ Alone ☐ With Family ☐ With Friends ☐ Other

• Employment/School: ____________________________________

• Support System (friends/family/religious/community)

Consent & Acknowledgment

I understand that the information I provide will be kept confidential except as required by law. I

consent to treatment and authorize Optimum Behavioral Health & Wellness, LLC to provide

appropriate care.

Patient or Parent/Guardian Signature: ____________________________________________

Date:__________________________________ m/d/y