General Information
    
Date: ______________
Legal Name: _________________________________________________
Preferred Name: ______________________________________________
Legal Guardian: ________________________________ Paperwork: Y/N
Case Manager: _______________________  Phone _________________
Spouse’s Name: _______________________________________________
Age: ______ Date of Birth: ___________ Sex: M/ F
Social Security Number: _____________________
Physical Address and P.O. Box: _________________________________
___________________________________________________________
Email Address: _______________________________________________
Phone Numbers:
Home_______________  Work _____________  Cell _____________
Can we leave a message at your home?  Y  N

Emergency Contact:
Name________________________        Relationship___________________
Phone: ______________________________________________________

Primary Care Dr. : __________________________Phone: _____________
Psychiatrist: _________________________  Phone___________________

Who referred you/how did you find us? _____________________________

Please list the medical issues you currently have:
____________________________________________________________
____________________________________________________________
____________________________________________________________

Please list the medications and dosages you are currently taking:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
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