Document Sample
					Instructions: Please complete each area of this application. Any incomplete areas may delay processing and scheduling. If additional space is needed, please use the back of the page or attach additional pages. Thank you.
For Office Use Only: DX: Intake Date: GAF: CODE: Other Provider: SPMI Acute

1930 Coon Rapids Boulevard, Coon Rapids, MN 55433  Phone: 763-427-7964  Fax: 763-427-7976  Name (First, M.I., Last): Address: City: Home Phone:
Use this number? Yes No

E-mail: Apt. #: State: Work Phone:
Use this number? Yes No


County: Cell Phone:
Use this number? Yes No

Date of Birth: Sex: F M Student Status: FT

Age: PT

Social Security #: Not a Student Level of Education: FT PT Not Employed

Place of Employment: Are you severely disabled? Yes Yes No

Employment Status: If yes, disability: No If yes, please explain: Separated Hispanic Divorced

Have you applied for disability? Marital Status: Race: White Single


Partnered Asian


Black/African American

American Indian or Alaska Native

Native Hawaiian or Pacific Islander Name of contact in case of emergency: Are you the head of the household? Yes

Other Race: Phone # of emergency contact: No Number of dependents: Annual Household Income Amount: Yes No If yes, when? Yes No

Total # in household (include foster children): Have you been a client at Family Life Center before?

If you have seen a provider at Family Life Center before, do you want to continue seeing him/her? Who referred you to Family Life Center? INSURANCE INFORMATION Do you have insurance? Medicare ID Number: Name of Insurance Company: Address of Insurance Company: Insurance ID Number: Policyholder Name: Spouse’s Name: Insurance Group Number: Name of Person Responsible for Payment: Spouse’s Date of Birth: Yes EAP Services? Yes No

No If yes, Please submit a copy of your insurance card(s) with this application. Medicaid ID Number:

Note: If you choose not to have claims sent to your insurance provider, please contact the business office at 763-746-9588.
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Please describe your reasons for seeking services at this point in time (i.e. symptoms): Depression Abuse Relationship Concerns Chemical Health Issues Anxiety Trauma Occupational Stress Eating Disorder Bipolar Grief/Loss Parenting Concerns Self Destructive Behaviors (i.e. cutting) Other: Please indicate the type of service you are seeking at Family Life Center: Individual Therapy Anger Management Group Marriage/Couples Therapy * Couple Communication Group Family Therapy DBT Group Psychiatric Services (medications) ** Life Steps Group

Parenting Group Transitions for Seniors Group Psychological Testing Other:

* If you are seeking Marriage/Couples therapy, please indicate the reasons below to assign an appropriate therapist. Communication Infidelity Domestic Abuse Substance Abuse Parenting Divorce Other ** If you are seeking psychiatry, your first appointment will be with a therapist for evaluation and referral as needed. Do you currently see a Primary Care Physician? Yes No If yes, Name:

If you see a Primary Care Physician, what is the Clinic Name? Do you currently see a Therapist (mental health)? Do you currently see a Psychiatrist (medications)? Yes Yes No No Yes Yes If yes, Name: If yes, Name: No No Yes If yes, When? If yes, When? No If yes, how many times?

Have you seen a Therapist (mental health) in the past? Have you seen a Psychiatrist (medications) in the past?

Have you ever been hospitalized for mental health reasons? When were you hospitalized? Do you have involvement with any other services? Social Services: Social Worker Interpreter Services Case Manager

Where were you hospitalized? Yes No If yes, indicate the type of service below: Home Care RN Independent Living Skills

ARMHS Worker

Please List Language: Please Explain:

Child Protection Services

Custody Determination Services Please Explain: Note: Family Life Center providers are not able to provide parenting or custody evaluations. Court Services for Divorce Please Explain: Psychiatric Evaluation Counseling Other Court Services, Court Ordered for: Anger Management Psychological Evaluation

Note: If you are court ordered for any service, you must submit a copy of the court order with this application. Please provide additional information or clarification regarding your court services below:

Other Services: Do you have any Legal Involvement? (i.e. Probation Officer) Yes No If yes, please explain below:


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Chemical History (Please indicate Past and/or Present use or N/A if never used): N/A N/A N/A N/A N/A N/A N/A Past Past Past Past Past Past Past Present Caffeine (coffee, pop) Present Nicotine (cigarettes) Present Alcohol (beer, booze) Present Marijuana (pot, dope, weed) Present Opiates, Narcotics, Heroin Present Prescription Drugs (over use) Present Inhalants (glue, aerosols) N/A N/A N/A N/A N/A N/A N/A Past Past Past Past Past Past Past Present Cocaine (crack, blow, powder) Present Designer Drugs (Ecstasy, MPP) Present Stimulants (meth, crank, crystal) Present Tranquilizers (valium, barbiturates) Present Hallucinogens (LSD, PCP, Mescaline) Present Over the Counter Drugs (diet pills, etc) Present Other: Yes Yes N/A Yes No N/A No No N/A N/A

Have you ever felt the need to CUT DOWN on your drinking or drug use? Have you ever been ANNOYED by criticism of your drinking or drug use? Have you ever felt GUILTY about your drinking or drug use? Yes No Have you ever felt the need for an eye opener to function at work or events?

Please list the type and dosage of all medications you are currently taking and the reason for treatment:
(If more space is needed, continue on the back or attach a list of your current medications.)



Do you have any allergies to medications or other allergies?



If yes, please list below:

Please indicate any serious medical conditions you are experiencing or have experienced in the past: High Blood Pressure Physical Impairments Heart Disease Cancer Liver Disease Diabetes Kidney Disease Other: Yes No Lung Disorders Yes No

Have any members of your immediate family experienced any of the medical conditions listed above? Do any relatives have a history of mental illness or substance abuse?

If yes, please explain below:

Do you have any children? Name(s) 1. 2. 3. 4. 5.



If yes, please list below: Lives with me: Part Time Part Time Part Time Part Time Part Time I have: Full Time Legal Custody Full Time Full Time Full Time Full Time Yes No Legal Custody Legal Custody Legal Custody Legal Custody Physical Custody Physical Custody Physical Custody Physical Custody Physical Custody


Are any of your children in foster care or not in your custody? I certify that the above information is accurate. Signature:

If yes, please explain below: Date:

Please be advised that this is only an application for services at Family Life Center. The completion of this application is not a guarantee of therapy, groups, or psychiatric services. If additional information is needed, you will be contacted as soon as possible. This application will take approximately 3 to 5 business days to process. You will be contacted to schedule your first appointment. Thank you for taking the time to complete this application.
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