<p> CJBH INTAKE FORM For Office Use Only Psychiatrist: Date: Time: Therapist: Date: Time: Appointment made by: </p><p>CLIENT: Last Name: Date of Birth: Age: First Name: Status: SSS #: Mailing Address: Gender: Occupation: Phone Number: Home ( ) Cell ( ) Referred by: Email:</p><p>INSURANCE: ___ BCBS ___ AETNA ____ OXFORD ___ CIGNA ___ VALUE OPTIONS ___ MEDICARE ___ EAP ___ MVA ____ WC ___ MEDICAID ____ OTHER</p><p>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#: </p><p>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 </p><p>If YES, please present your FSA/HRA VISA DEBIT card to the front desk at the time of your registration.</p><p>MOTOR VEHICLE & WORKER’S COMPENSATION CASES: Please provide the following Case Managers Name: Contact Number: Date of Loss/Accident: Claim #</p><p>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:</p><p>Appointment Preferences: How soon do you need the appointment?</p><p>Page 1 of 3 Male or Female Provider? Or whoever comes first Day , Afternoon, Evening or Weekend Appointment? Specify your needs</p><p>Please answer these accurately </p><p>Chief Complaint:</p><p>Any history of head injury?</p><p>Why do you feel like you need an appointment:</p><p>_____ 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?</p><p>Were you seeing a Psychiatrist or Therapist before? If YES, when? For how long? What was the diagnosis given?</p><p>Please list your current prescribed medications</p><p>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?</p><p>Page 2 of 3 Are you seeking Suboxone/Opiod Addiction Treatment? </p><p>To ensure fast scheduling of your appointment, please make sure to:</p><p>Send LEGIBLE copies of: </p><p>1. Insurance card/s (FRONT & BACK)</p><p>2. Driver’s license / PICTURE ID CARD</p><p>**** You can send back this form thru email at [email protected] or fax at (908) 272- 7502.</p><p>**** 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. </p><p>Thank you.</p><p>Page 3 of 3</p>