Psychiatric Evaluation Pre-Visit Information Form

If you prefer to not submit your information online please contact our office at (518) 438-0033.

Name:

Date of Birth:

Address 1:

Address 2:

City:

Zip:

If you would prefer NOT to be contacted by email or at any of the numbers below, just leave blank.

Phone (home):

Phone (cell):

Phone (work):

Email:

Preferred method of contact:

Mail

Phone

We ask for this information only to save you the time of explaining your problems to our staff, which you may choose NOT to do if we determine that your insurance may not cover our services, in which case you may decide to pursue treatment elsewhere.

Insurance Company:

Insurance Number:

How did you learn about us?

Summary of current problems for which you are seeking help:

Have you ever been hospitalized for psychiatric reasons?

Yes

Have you ever received any form of psychiatric or psychological treatment?

Yes

With whom?

When?

Current medical problems?

Current psychiatric medications, if any:

Current medical medications, if any:

Any problems with alcohol or other substances of abuse?

Any current legal problems?

Anything else we should know?