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Intake C -Intake Form

LifeBack
4 Princess Rd
Suite 206
Phone 609-482-3701
Fax 609-482-3702
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Questions on this form will be utilized to gather information, confirm your receipt of information, and verify contact information.  
Are you currently taking prescribed medication(s)?
Yes  
No  
List of Current Medications
  Medication Name Dosage Frequency Side Effects or Adverse Reactions Reason
1
2
3
4
5
6
7
8
* Psychotropic Medication History    History of psychotropic medications, name, dosage, frequency, side effects and efficacy OR any other relevant medication information not listed elsewhere (Write DENIED if no history/no additional medications
Psychiatric Advanced Directives
Do you have a Psychiatric Advanced Directives?
Yes   No  
If yes, may we have a copy?
Yes   No  
N/A    
Pt's Immunization Records    *ONLY FOR PTS UNDER 18* Please ask pt's parents/guardians about pt's immunization records
N/A - PT is an adult   PT/Parent or Guardian confirm PT's immunizations are up to date and/or has been encouraged to follow up with PT's PCP & given referrals if needed    
I agree to allow LifeBack to contact me via the contact points listed below. I understand that I can regularly update LifeBack if my contact preference change.
Mail to home address  
Mail to alternate address  
Email  
Text message  
Leave a voicemail message  
Your signature below indicates:

1. LifeBack has provided you with the following: (additional copies can be found in the lobby and on our website):
       • Information about Psychiatric Advance Directives.
       • Information on HIV/AIDS testing sites.
       • Information on how to file complaints and/or grievances.
       • Information on Summer Heat and Sun Risks for Antipsychotic Medication.

2. I understand that I can regularly update LifeBack if my contact preference changes

3. I will inform LifeBack if my insurance information change.

4. I give LifeBack permission to contact my emergency contact, listed in my PT record, in the case of an emergency including concerns for my immediate safety.

5. I understand that for my protection and the protection of other PTs, visitors and employees the premises are monitored by closed circuit surveillance.
Your signature below indicates you have read, understand, and agree with the information listed above.  Additional you certify that the above statements are true and correct to the best of your knowledge.
Signature
Signer Type:
Name:
Signature:
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