Policy Holder D.O.B. (mm/dd/yyyy) Relationship Policy Holder Address City State Zip Code Policy Number Group Number MENTAL HEALTH HISTORY/STATUS What problems are you seeking help for? Past Mental Health Treatment YES NO Have you ever been hospitalized for psychiatric reasons? If yes, when and where? YES NO Have you ever had outpatient treatment by a psychiatrist? If yes, when and by whom? YES NO Have you ever received counseling or psychotherapy in the past? If yes, when and by whom? Please List any psychiatric medication you have or are taking: Medication Date Side Effects/Benefits
Policy Holder D.O.B. (mm/dd/yyyy) Relationship Policy Holder Address City State Zip Code Policy Number Group Number MENTAL HEALTH HISTORY/STATUS What problems are you seeking help for? Past Mental Health Treatment Have you ever been hospitalized for psychiatric reasons? YES NO If yes, when and where? Have you ever had outpatient treatment by a psychiatrist? YES NO If yes, when and by whom? Have you ever received counseling or psychotherapy in the past? YES NO If yes, when and by whom? Please List any psychiatric medication you have or are taking: Medication Date Side Effects/Benefits
New-Adult-Intake-Forms-Combined.docx