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Preadmission Assessment
Welcome to The Mind-Body Collaborative, Inc. Please fill out this assessment as honestly as possible so we are able to prepare a proper treatment plan that is customized to the patient's needs.
Please also visit our website: www.ATX-TheMindBodyCollaborative.com
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Email
*
Your email
Patient Name
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Your answer
Who is filling out the form?
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Your answer
What is the relationship to the patient?
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Self
Parent/Guardian
Provider
Other:
Patient date of birth
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MM
/
DD
/
YYYY
Patient address
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Your answer
Patient Phone #
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Your answer
Patient Email
Your answer
Parent/Guardian Name
Your answer
Parent/Guardian Ph#
Your answer
Parent Guardian Email
Your answer
Is there a guarantor?
Yes
No
Clear selection
If yes, who will the guarantor be?
Your answer
Referred by?
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Your answer
Presenting problem/crisis/precipitating event that has lead to seeking treatment at this time.
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Your answer
Have there been previous psychiatric treatments?
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Your answer
Please describe treatment history. (Including admissions not related to presenting problems/events.)
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Your answer
Does the patient have an outside provider?
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Yes
No
If yes, please provide the name/role of all outpatient providers including but not limited to therapists, registered dietician, psychiatrist, recovery support, or other.
Your answer
Does the patient have substance abuse?
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Yes
No
What is the patient's medical history?
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Your answer
Please list current medications (if none N/A).
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Your answer
Are there any disordered eating or eating disorder concerns?
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Yes
No
If yes, please describe.
Your answer
What is the patient's marital status?
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Married
Single
Divorced
Widowed
Other:
With whom does the patient live?
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Your answer
Does the patient have children?
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Yes
No
Is the patient currently employed?
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Yes
No
On average, how many hours of sleep per night does the patient get?
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Your answer
Has the patient had any unanticipated weight gain?
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Yes
No
Has the patient had an unanticipated weight loss?
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Yes
No
Has the patient experienced suicidal ideation?
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Yes
No
If yes, is the patient currently experiencing these thoughts?
Your answer
Has the patient engaged in suicidal behavior?
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Yes
No
If yes, please include a brief description (date, methods used, medical attention required, any significant stressors).
Your answer
Has the patient experienced any homicidal ideation?
Your answer
Does the patient have a history of self harm?
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Yes
No
If yes, how and where does the patient engage in self-injurious behaviors?
Your answer
Please describe the family history and family dynamics.
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Your answer
A copy of your responses will be emailed to the address you provided.
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