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Initial Evaluation Form

Fill out and submit the form below with the correct information.

MM slash DD slash YYYY
Name
Address
OK TO LEAVE A MESSAGE ON MACHINE AT HOME?
OK TO LEAVE A MESSAGE WITH A FAMILY MEMBER?
OK TO LEAVE A MESSAGE AT WORK (VOICEMAIL)?
OK TO LEAVE A MESSAGE ON CELL PHONE?
MM slash DD slash YYYY
ROLE IN FAMILY UNIT CIRCLE ONE
OK TO LEAVE A MESSAGE ON CELL PHONE?
MARITAL STATUS

EMERGENCY CONTACT

Name
Address
I authorize Healthy Mind to contact the above-named person in case of an emergency.
REFERRAL SOURCE
THERAPIST
Name
Address

PHARMACY INFORMATION

LIST ALL PSYCHIATRIC MEDICATIONS THAT YOU ARE CURRENTLY TAKING

LIST ALL PSYCHIATRIC MEDICATIONS THAT YOU ARE CURRENTLY TAKING
NAME OF MEDICATION
DOSAGE/FREQUENCY
 
Name

PATIENT-PROVIDER AUTHORIZATIONS AND AGREEMENTS.

Authorizations and Agreements with Healthy Mind. Please read carefully and sign. The paragraphs below contain several agreements.
MM slash DD slash YYYY

FINANCIAL RESPONSIBILITY

I understand and agree that I am responsible for the fees to Healthy Mind before services are rendered.

PRIMARY CARE PHYSICIAN CONTACT AUTHORIZATION

hereby authorize Healthy Mind
PLEASE CHECK ONE
I may revoke this authorization at any time except to the extent that action has been taken in reliance upon it. If I do not revoke this authorization, it will expire one (1) year after I have terminated treatment.
MM slash DD slash YYYY

INFORMED CONSENT FOR TREATMENT

(name of patient), agree and consent to participate in behavioral healthcare services offered and provided by Healthy Mind, a behavioral health care provider. I understand that I am consenting and agreeing only to those services that the above-named provider is qualified to provide within: (1) the scope of the provider's license, certification, and training; or (2) within scope of license, certification, and training of the behavioral health care provider directly supervising the services
PATIENT NAME
MM slash DD slash YYYY

Fostering mental wellness through expert care, compassion, and individual growth.

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Office Hours

Mon | 7:30am-9:00am
Mon - Fri | 6:40pm - 8:00pm (Minus Wednesday)
Wed | 9:00 am - 7:00 pm
Sat | 9:00 am - 2:00 pm
Sundays (By Appoinment only)

  • Office Hours
  • Mon :
  • 7:30am-9:00am
  • Mon - Fri :
  • 6:40pm - 8:00pm (Minus Wednesday)
  • Wed :
  • 9:00 am - 7:00 pm
  • Sat :
  • 9:00 am - 2:00 pm
  • Sundays :
  • (By Appoinment only)

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