Solace Counseling's New Patient Form

First Name *

Last Name *

Maiden Name

Email Address *

Date of Birth (mm/dd/yyyy) *

Home Phone

Cell Phone Number

Street Address *

City *

State *

Zipcode *

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Insurance Company *

Insurance Company Phone # *

Policy Number (Member ID)

Group Number

Name of Insured (if different than patient)

Insured's Social Security Number *

Insured's DOB (if different than patient)

Insured’s Address (if different than patient’s address)

Insured's Street Address

Insured's City

Insured's State

Insured's Zipcode

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Source of Referral *

Source of Referral (if not listed)

Living Arrangement *

Living Arrangement (if not listed)

Employer

Years employed by this employer

Legal Status *

Legal status (if not listed)

Relationship Status *

Partner's Name

Number of children 18 and under

Are you pregnant?

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Number of times you’ve received psychiatric/counseling services in the last 6 months

Number of hospital admissions in the last 12 months

Do you currently have a medical condition? *

Medical Condition

Medications (list all)

Substance abuse history? *

Do you often use larger amounts of alcohol or drugs or use them for a longer time than you had planned or intended?

Did you try to cut down on alcohol or drugs and were unable to do so?

Did you spend a lot of time getting alcohol or drugs, using them, or recovering from their use?

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What drugs caused you the most serious problems?

Substance abuse treatment history? *

Prior Detox Admissions

Prior Non-Detox Admissions

Months since last discharge from any treatment program

In the past 30 days, how many days were you abstinent from all substances?

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Medical Release Information

Purpose of disclosure or release: To allow for dialogue between this facility, Solace Counseling Associates, and , as the provider of your behavioral health plan.

Scope of disclosure or release: Admission assessment and evaluation, health history, prior chemical dependency treatments, financial assessment, diagnosis, plan of treatment, current medications, interface with other medical or mental health providers, discharge plan, prognosis, progress of treatment, interruptions to treatment, ancillary providers, discharge disposition, individual and group process notes, and any other information requested by your insurance company not stated above.

You are advised: That your records are confidential and cannot be disclosed without your written authorization, except as otherwise provided by law. You are further advised that records pertaining to the diagnosis and treatment of HIV/AIDS, Psychiatric/Mental Health, Psychological Disorders and Alcohol/Chemical dependency will not be released, unless you have given your specific consent to release as indicated by this document.

A facsimile or copy of this authorization may be accepted as original.

This authorization may be revoked at any time, except to the extent that action has already been taken in reliance upon it. This authorization shall expire five years from the date of your signature, unless otherwise specified by date, event or condition as follows:

RELEASE

I, , whose Social Security number is , hereby authorize the staff of Solace Counseling Associates, to release information to . I also authorize release of any and all information necessary to monitor the system of care and/or assist in the resolution of complaints.

I agree to the release as stated above.

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