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Patient Intake Form
Intake Form for Laguna Behavioral
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* Indicates required question
Email
*
Your email
First name
*
Your answer
Last Name
*
Your answer
Date of Birth (Month xx / Day xx / Year xxxx)
*
Your answer
Phone Number
*
Your answer
Current Street Address
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Your answer
Currently occupied City
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Your answer
Currently occupied State
*
Your answer
Currently occupied ZIP Code
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Your answer
Gender
*
Male
Female
Required
How were you referred to our office?
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Your answer
Will you be using your insurance to visit our office?
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Yes
No
What Medical Insurance do you have?
*
Choose
Aetna
Anthem Blue Cross
Blue Cross / Blue Shield
Blue Shield
Cigna
Healthnet
Meritain
Oscar
United Healthcare
Tricare
Other
Not Applicable
What type of plan is your insurance plan?
*
HMO
PPO
Open Access
Choice Plus
Not Applicable
Other:
Your Insurance Member ID Number (If not applicable please answer N/A)
*
Your answer
On the back of the Insurance card there will often be a "Provider service phone number" or "Mental Health Toll Free Phone Number". Could you provide it below please? (If not applicable please answer N/A)
*
Your answer
For what reason will you be coming in for a visit?
*
Depression
Anxiety
Panic Disorder
ADD/ADHD
OCD
Individual Therapy
Family Therapy
Other:
Required
I would like to schedule for
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Psychiatry (To be prescribed medication / manage an existing prescription of medication)
Therapy (For talk therapy)
T.O.V.A. Test / Psychological Testing (For ADD, ADHD, or Psychological Testing)
Required
(IF you would like to meet with a psychiatrist) could you please provide a list of all of the medications you're currently taking? (Name and dosage per day) | If none please write N/A)
*
Your answer
At this time are you currently taking
*
Valium (Diazepam)
Xanax (Alprazolam)
Ativan (Lorazepam)
Klonopin (Clonazepam)
None of the above
Other:
Required
Will your visit be due to:
*
Yes
No
Requesting Time off of work?
Requesting Disability?
Requesting Worker's Compensation?
Being involved in any legal matters at present time?
Requiring the doctor to fill out any paperwork?
Yes
No
Requesting Time off of work?
Requesting Disability?
Requesting Worker's Compensation?
Being involved in any legal matters at present time?
Requiring the doctor to fill out any paperwork?
Have you:
*
Yes
No
Had any recent psychiatric hospitalization?
Attended an intensive outpatient program for psychiatric or chemical dependency problems?
Attended any detox or rehab programs?
Do you have any past history of suicide attempts?
Yes
No
Had any recent psychiatric hospitalization?
Attended an intensive outpatient program for psychiatric or chemical dependency problems?
Attended any detox or rehab programs?
Do you have any past history of suicide attempts?
If you answered yes to any of the above questions regarding medical programs, please detail when you were discharged from said program, and for what reason you attended said program. (If not applicable please enter N/A)
*
Your answer
Are you currently taking any opiates?
*
Yes
No
Additional Notes / Comments
Your answer
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