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Intake B. Patient 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 preferences.  Information regarding specific health topics have been sent to you via email, copies are also available by request at any time and are available in the main lobby.
List of Current PSYCHIATRIC Medications    If you are not taking any medications please write NONE in Row#1. Use "additional medication" field if you need additional space.
  Medication Name Dosage Frequency Is this medication effective for treating targeted symptoms/condition Side Effects or Adverse Reactions Reason
1
2
3
4
5
List of Current NON-PSYCHIATRIC Medications    If you are not taking any medications please write NONE in Row#1. Use "additional medication" field if you need additional space.
  Medication Name Dosage Frequency Is this medication effective for treating targeted symptoms/condition Side Effects or Adverse Reactions Reason
1
2
3
4
5
* Additional Medication Information    Include any medications you were unable to list above. Also, include any relevant information re: your experience with previously prescribed psychotropic medication(s).
* Name of Primary Care Physician/Provider
* Date of Last Physical Exam
* Current Medical Providers - are you receiving care from any other medical providers?    If "yes" please include name of provider/facility and condition being treated.
* Current Medical Conditions    Do you have any major/significant medical conditions your treatment team should be aware of? Include name of illness/issue, onset, treatment being received, is condition stable, and any other important details.
* Did you experience any birth complications, childhood developmental delays/disabilities, learning disorders or other special needs/circumstances during your early life development?
* Were you exposed to drugs or alcohol in utero?
* Immunizations    *ONLY FOR PATIENTS UNDER 18*
N/A Patient is an adult   Patient/Parent confirm that immunizations are up to date   Immunizations are not up to date (include details)  
* Highest Education Level
Highschool  Associate Degree  Bachelor's Degree 
Master's Degree  Doctoral Degree  Other  
  
* Employment Status
Employed full-time  Retired  Short-term disability 
Employed part-time  Student  Long-term disability/SSDI 
Unemployed (seeking employment)  Stay at home parent   Other 
  
* Military Experience
No Military Experience   Active Duty  Retired/Veteran 
Reserves  Deployment History  Combat Exposure 
  
Psychiatric Advanced Directives
* Do you have a psychiatric advanced directives?
Yes   No  
* If yes, may we have a copy?
Yes   No  
N/A    
If you answered "no" and you would like information re: psychiatric advanced directives, information has been sent to you via email and is available in the main lobby. If you have questions, please ask your Intake Specialist.
Communication Preferences
* I allow LifeBack to contact by the methods I have selected below. at I can regularly update LifeBack if my contact preference change.
Phone Call 
Voicemail 
Mail to Home Address 
Mail to Alternate Address 
Email 
Text Message 
Your signature confirms that you have read, understand, and agree with the information listed in this form and to the information listed below.  

1. LifeBack has provided you with the following information: (additional copies are available by request, can be found in our mail lobby and are available 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.
               PA Patients Only - A Copy of The Non-Discrimination in Services Policy Statement.

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

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

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

5. I understand that for my protection and the protection of other Patients, visitors and employees the premises are monitored by closed circuit surveillance.
Signature
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