New Patient Paperwork for George PMHNP-BC

Psychiatric Intake Form

Please fill out the sections below for your appointment today.

First Name

Last Name

Phone

Current Medications

1. Please list all current medications, including psychiatric medications and any others you are taking.

Pharmacy Information

2. Please provide the name and location of the pharmacy

Allergies food or medication

Mental Health History

a. Have you ever been diagnosed with a mental illness? If so, please specify the illness and your age at the time of diagnosis.

b. Have you ever received mental health treatment or counseling? If so, please specify the type of treatment received and when.

3. c. Have you ever been hospitalized for a mental health reason? If yes, please specify the reason, the name of the hospital, and the dates of admission and discharge.

Medical History

a. List all current medical providers and their specialties.

b. List all current medical diagnoses.

4. c. List any surgeries you have had and the year they were performed.

Personal Information

a. Marital status.

b. Occupation.

d. Primary language spoken.

5. e. Highest level of education completed.

Support System

a. Who do you consider your support system that you could turn to in a time of need?

6. b. Are there any family members or close friends who are currently providing support or who could potentially be involved in your treatment?

Trauma History

a. Have you ever experienced emotional abuse?

b. Have you ever experienced physical abuse?

7. c. Have you ever experienced sexual abuse?

Current Stressors:

8. Please list any current stressors you are experiencing, such as financial stress, school stress, relationship stress, etc.

Best Practice Questions

a. Do you have any concerns about starting psychiatric medications? If so, please specify.

b. Are you interested in counseling or therapy as part of your treatment plan?

c. Are there any cultural, religious, or spiritual beliefs that you would like to incorporate into your treatment?

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New Patient Paperwork for George PMHNP-BC

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