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Registration Form - General Info
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Registration Form- Family Mental Health History
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REGISTRATION FORM
Our Registration Form Is In Three Sections, (General, Employment, Health). Please Complete And Submit Each Section
GENERAL HEALTH AND MENTAL HEALTH SECTION
Employment - General Health
PRIMARY CARE PHYSICIAN (PCP) NAME
First Name
Last Name
PCP ADDRESS
Street
Address line 2
City
Zip Code
Country
Please select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern &, Antarctic Lands
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island &, McDonald Islands
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia &, South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Kosovo
Croatia
State
Please select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Ashmore and Cartier Islands
Australian Antarctic Territory
Australian Capital Territory
Christmas Island
Cocos (Keeling) Islands
Coral Sea Islands
Heard Island and McDonald Islands
Jervis Bay Territory
New South Wales
Norfolk Island
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
PCP PHONE NUMBER
PCP TREATMENT UPDATE (I would like for my PCP to be occasionally informed about my treatment?)
Yes
No
SIGNATURE (By typing your name, you are consenting to using that as your electronic signature)
RELATIONSHIP TO PATIENT
DATE
Month
Please select
1
2
3
4
5
6
7
8
9
10
11
12
Day
Please select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Please select
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
2069
2070
2071
2072
2073
2074
2075
2076
2077
2078
2079
2080
2081
2082
2083
2084
2085
2086
2087
2088
2089
2090
2091
2092
2093
2094
2095
2096
2097
2098
2099
2100
2101
2102
2103
2104
2105
2106
2107
2108
2109
2110
2111
2112
2113
2114
2115
2116
2117
2118
2119
2120
2121
2122
2123
1. Have you previously received any type of mental health services. (psychotherapy, psychiatric? services, etc.)?
Yes
No
NAME OF THERAPIST(S)
* Have you ever been prescribed psychiatric medication?
Yes
No
* Please List And Provide Dates
2. How would you rate your current physical health? (Please Choose)
Poor
Unsatisfactory
Satisfactory
Good
Very good
* Please list any specific health problems you are currently experiencing
3. How would you rate your current sleeping habits? (Please Choose)
Poor
Unsatisfactory
Satisfactory
Good
Very good
* Please list any specific sleep problems you are currently experiencing
4. How many times per week do you generally exercise?
* What types of exercise do you participate in?
5. Please list any difficulties you experience with your appetite or eating patterns:
6. Are you currently experiencing overwhelming sadness, grief or depression?
Yes
No
* If yes, for approximately how long?
7. Are you currently experiencing anxiety, panic attacks or have any phobias?
Yes
No
* If yes, when did you begin experiencing this?
8. Are you currently experiencing any chronic pain?
Yes
No
* If yes, please describe
9. Do you drink alcohol more than once a week?
Yes
No
10. How often do you engage in recreational drug use?
Daily
Weekly
Monthly
Infrequently
Never
11. Are you currently taking any prescription medication?
Yes
No
* Please list
12. Do you have any allergies?
13. Are you currently in a romantic relationship?
Yes
No
* If yes, for how long?
* On a scale of 1-10, how would you rate your relationship?
14. What significant life changes or stressful events have you experienced recently
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