Step 1 of 520%CompanyThis field is for validation purposes and should be left unchanged.Provider Name:Select ProviderHeather Humphrey, APRNMali Sirisena, APRNKristen (Mandie) Shepherd, APRNLaura Williams, APRNPatient's Legal Name First Last Preferred NameIs the patient a minor? Yes NoParent/Guardian Name First Last Relationship to PatientPatient Phone Number: (Parent/Guardian number if patient is a minor)Email Address Patient Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Patient Date of Birth Month Day Year Patient Gender Male Female Non-Binary Trans-Male Trans-Female OtherPlease SpecifySexual Orientation: Straight / Heterosexual Gay or Lesbian Bisexual Pansexual Asexual Queer Questioning / Unsure Another identity Prefer not to sayAnother Identity:Marital / Relationship Status: Single Married Partnered Separated Divorced WidowedCurrent Living Situation: Live alone Live with spouse/partner Live with parents/family Shared housing/roommates Group home / residential program Other - Please SpecifyHighest Level of Education Completed: Some high school High school diploma / GED Some college Associate’s degree Bachelor’s degree Graduate / Professional degree Other - Please SpecifyCurrent employment or primary daily activity: Full-time work Part-time work Student Unemployed Stay-at-home parent Retired On disabilityJob title / field (if applicable):Current School:Grade:Does the patient have: IEP (Individualized Education Program) 504 Plan Informal support/learning plan None of the above UnsureAny school or learning concerns (attention, behavior, learning difficulties, bullying, etc.)?Describe the reason you are seeking help or servicesPlease describe your symptoms, concerns, or goals.Are you experiencing any of the following symptoms? Please select all that apply. Feeling down or depressed Unable to enjoy activities Loss of interest in activities Problems with sleep Concentration difficulties Forgetfulness Changes in appetite Fatigue Racing thoughts Impulsivity Increased risky behavior Increased libido Decreased libido Excessive energy Suspiciousness Increased irritability Crying spells Excessive guilt Excessive worry Anxiety attacks Hallucinations Avoidance Thoughts of self-harmHow long have these concerns been present? Less than 1 month 1–6 months 6–12 months 1–5 years More than 5 yearsHave you had mental health treatment in the past? (Therapy, Medication Management, or Testing) Yes NoPlease list where and whenCurrent MedicationsPlease list all of the medications that you're currently taking. Please add each medication as a separate line. You can use the "plus" icon to add a new line.MedicationDosage Add RemovePast Psychiatric Medications (with presented list of meds)Suicide Risk AssessmentTrauma HistorySubstance UseMedical HistoryPrimary Care Provider / Pediatrician:Medical ConditionsHave you ever been diagnosed with any of the following? (Check all that apply.) High blood pressure Heart disease or irregular heartbeat High cholesterol Diabetes Thyroid problems Seizures / epilepsy History of concussion or serious head injury Stroke or TIA Kidney disease Liver disease / hepatitis Sleep apnea Asthma or chronic lung disease Chronic pain condition Neurologic conditions (e.g., Parkinson’s, multiple sclerosis) Autoimmune diseaseSurgeries and HospitalizationsAllergiesFamily HistoryHave any close family members (parents, siblings, children, grandparents, aunts/uncles) had the following? Depression Anxiety Bipolar disorder Schizophrenia or other psychotic disorder ADHD Autism spectrum disorder Substance use problems (alcohol or drugs) Suicide attempt Death by suicide None of the above / None knownIf you wish, list relatives and conditions: (e.g., "sibling - depression"):Do you have insurance? Yes NoPolicy Holder's Name First Last Policy Holder's Date of Birth Month Day Year Policy Holder's EmployerInsurance Company Name Aetna Ambetter AMCO / Stratose / Zelis Blue Advantage Blue Cross Blue Shield Cigna / Evernorth Coventry Employer's Health Coalition (EHC) Government Employees Health Administration (GEHA) - OUT OF NETWORK Health Advantage Key Benefit Administrator Municipal Health Benefit Fund QualChoice Tricare UMR - OUT OF NETWORK UMR University of Arkansas United Healthcare - OUT OF NETWORK Other - Please SpecifyPhone number for Mental Health, Customer Service, or Eligibility/BenefitsYou can find this on the back of the card.ID / Policy #Group / Plan / Division #Do you have secondary insurance? Yes NoSecondary Insurance Policy Holder's Name First Last Secondary Insurance Policy Holder's Date of Birth Month Day Year Secondary Insurance Policy Holder's EmployerSecondary Insurance Company Name Aetna Ambetter AMCO / Stratose / Zelis Blue Advantage Blue Cross Blue Shield Cigna / Evernorth Coventry Employer's Health Coalition (EHC) Government Employees Health Administration (GEHA) - OUT OF NETWORK Health Advantage Key Benefit Administrator Municipal Health Benefit Fund QualChoice Tricare UMR - OUT OF NETWORK UMR University of Arkansas United Healthcare - OUT OF NETWORK Other - Please SpecifySecondary Insurance phone number for Mental Health, Customer Service, or Eligibility/BenefitsYou can find this on the back of the card.Secondary Insurance ID / Policy #Secondary Insurance Group / Plan / Division #
