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CJBH INTAKE FORM For Office Use Only Psychiatrist: Date: Time: Therapist: Date: Time: Appointment made by:

CLIENT: Last Name: Date of Birth: Age: First Name: Status: SSS #: Mailing Address: Gender: Occupation: Phone Number: Home ( ) Cell ( ) Referred by: Email:

INSURANCE: ___ BCBS ___ AETNA ____ OXFORD ___ CIGNA ___ VALUE OPTIONS ___ MEDICARE ___ EAP ___ MVA ____ WC ___ MEDICAID ____ OTHER

PRIMARY INSURANCE SECONDARY INSURANCE Subscriber’s Full Name: Subscriber’s Full Name: Relation: Relation: Date of Birth: Date of Birth: Insurance ID# SSS#: Insurance ID# SSS#:

If the patient is a child, and there is a LEGAL BATTLE in regards to CHILD CUSTODY, RIGHT TO MAKE MEDICAL DECISION OR FINANCIAL ARRANGEMENTS MADE BY COURT, please provide our office the LEGAL DOCUMENTATION/S regarding this matter. Our office is not responsible for any mistakes when PROPER LEGAL DOCUMENTATION is not presented beforehand. Please fill if applicable: Does your plan have FSA/HRA Account: ____ YES ____ NO

If YES, please present your FSA/HRA VISA DEBIT card to the front desk at the time of your registration.

MOTOR VEHICLE & WORKER’S COMPENSATION CASES: Please provide the following Case Managers Name: Contact Number: Date of Loss/Accident: Claim #

EMPLOYEE ASSISTANCE PROGRAM: Please provide the following and the authorization paper by your EAP Name of the provider authorization was given: Authorization Number: Number of visits allowed: Effective and End date of Authorization: Case Manager’s Full Name: Contact Number:

Appointment Preferences: How soon do you need the appointment?

of 3 Male or Female Provider? Or whoever comes first Day , Afternoon, Evening or Weekend Appointment? Specify your needs

Please answer these accurately

Chief Complaint:

Any history of head injury?

Why do you feel like you need an appointment:

_____ Psychiatrist(Medication Management) ____ Psychotherapist (Counselling) Who do you want to see? ______Both (Medication Management & Counselling) How soon do you need the appointment? Any suicidal Ideation? Or Attempt? If Yes, when? Any Homicidal Ideation? Or Attempt? If Yes, when? Any history of physical abuse/sexual or violence?

Were you seeing a Psychiatrist or Therapist before? If YES, when? For how long? What was the diagnosis given?

Please list your current prescribed medications

Is there any history of drug or substance abuse? Was there treatment for the abuse? Any Inpatient Hospitalization? What was the reason for admission? Please specify admission date/s and treatments received. Why did you stop seeing/ switched Psychiatrist or Therapist?

of 3 Are you seeking Suboxone/Opiod Addiction Treatment?

To ensure fast scheduling of your appointment, please make sure to:

Send LEGIBLE copies of:

1. Insurance card/s (FRONT & BACK)

2. Driver’s license / PICTURE ID CARD

**** You can send back this form thru email at [email protected] or fax at (908) 272- 7502.

**** Please allow 24-48 hours/ 2 business days to be called back to set up an appointment. We will do our best to schedule you ASAP. Our office normally calls between 3:00 – 7:00 PM for scheduling NEW PATIENTS.

Thank you.