Submit
Cancel

Intake b. Patient Intake Form

LifeBack
4 Princess Rd
Suite 206
Lawrenceville, New Jersey 08648
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:  
Welcome and Thank You for Choosing LifeBack
The questions on this form will be utilized to gather general information that will help us provide you with the best care possible.  This form will also be utilized to confirm your receipt of information regarding specific health topics which have been sent to your email.
* What are your pronouns?    (she/her, he/him, they/them etc.)
* Sex Assigned at Birth
* Gender Identification
List of Current PSYCHIATRIC Medications    If you are not taking any medication please write "NONE" in Row#1. Use the "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 medication please write "NONE" in Row#1. Use the "Additional Medication" field below 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
* Have you ever had a psychiatric evaluation?
* Medical History
NONE  Cancer  COPD 
High Blood Pressure  Anemia  Asthma 
High Cholesterol  Seizure Disorder  Pulmonary Embolism 
Chronic Pain  GERD  Cardiovascular Issues 
IBS  Coronary Artery Disease  Liver Disease 
Kidney Disease  Pancreatitis  Elevated Liver Enzymes 
Hepatitis - indicate type  Diabetes - indicate type  Hyper/Hypo Thyroid 
  
* 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.
* Developmental History
  Do any of the following apply to you:
Premature Birth
Birth Complications
Developmental Delays
Social Delays
Learning Disorder(s)
IEP (individualized education plan)
504
* Family History:    Please include significant mental health, substance use and/or medical history pertaining to your immediate family.
* Nicotine Use
Current Smoker   Current use of other nicotine products - (chew, vape)  I AM INTERESTED IN CESSATION OPTIONS  
Former Smoker (include quit date)  Former use of other nicotine products - (include quit date)  Never smoked or used nicotine products 
  
* 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 directive?
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.
Your signature confirms that you have read and understand the information included in this form.

1. LifeBack has provided you with the following information: (additional copies are available by request, can be found in our lobby and are available on our website).
       • Information about Psychiatric Advance Directives.
       • 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 it is my responsibility to inform LifeBack if my:
     * Contact preferences change
     * If my address or phone number change
     * If there are any changes to my insurance.

3. I give LifeBack permission to contact the emergency contact, listed in my Patient record, in the event of any emergency including concerns for my immediate safety or the safety of others.

4. I understand that for my protection and the protection of other Patients, visitors and employees the premises are monitored by closed circuit surveillance.
* Electronic Signature    Type your full name
* Relationship to Patient    If you are signing as a parent, guardian, or personal representative of the Patient, please indicate relationship or authority. TYPE N/A IF NOT APPLICABLE
* Date
I UNDERSTAND THAT BY TYPING MY NAME ABOVE, THIS SERVES AS MY ELECTRONIC SIGNATURE
Form Updates
Name Date Action
    Form Started
  1. Click the "Submit" button to save the data entered on this form.
  2. Click the "Cancel" button to exit without saving recent updates on this form.