Registration

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Date

Basic Patient Information

Email Address*

Last Name*

Gender*

Date of Birth*

We apologize for the inconvenience, we only see patients 16 years of age or older.

Cell #*

Work #

Emergency Contact Name*

Primary Phone #*

Relationship

Resides with

Address

City

State

ZIP Code

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Emergency Contact

Basic Patient Information

Email Address:

{Email Address:14}

Last Name:

{Last Name:10}

Gender:

{Gender:227}

Date of Birth:

{Date of Birth:13}

Cell #:

{Cell #:18}

Work #:

{Work #:17}

Emergency Contact Name:

{Emergency Contact Name:21}

Primary Phone #:

{Emergency Contact’s Primary Phone:22}

Relationship:

{Relationship:497}

Resides with:

{Resides with:498}

Address:

{Address:292}

City:

{City:293}

State:

{State:15.4}

ZIP Code:

{ZIP Code:291}

Emergency Contact:

{Emergency Contact:19}

Patient Health Questionnaire(PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems? Use the following scale to choose the most appropriate number for each situation:

1. Little interest or pleasure in doing things:

{1. Little interest or pleasure in doing things:229.1}

2. Feeling down, depressed, or hopeless:

{2. Feeling down, depressed, or hopeless:230.0}

3. Trouble falling or staying asleep, or sleeping too much:

{3. Trouble falling or staying asleep, or sleeping too much:231.1}

4. Feeling tired or having little energy:

{4. Feeling tired or having little energy:232.1}

5. Poor appetite or overeating:

{5. Poor appetite or overeating:233.1}

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down:

{6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down:234.1}

7. Trouble concentrating on things, such as reading the newspaper or watching television:

{7. Trouble concentrating on things, such as reading the newspaper or watching television:235.1}

8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual:

{8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual:236.1}

9. Thoughts that you would be better off dead or of hurting yourself in some way:

{9. Thoughts that you would be better off dead or of hurting yourself in some way:237.1}

Your PHQ-9 Scale Total Score Is:

{Your PHQ-9 Scale Total Score Is:242}

Suicidal Ideations (CCSR)

In the past month have you wished you were dead or wished you could go to sleep and not wake up?:

{In the past month have you wished you were dead or wished you could go to sleep and not wake up?:296.0}

In the past month have you actually had any thoughts of killing yourself?:

{In the past month have you actually had any thoughts of killing yourself?:297.0}

Have you been thinking about how you might do this?:

{Have you been thinking about how you might do this?:299.0}

In the past month have you had these thoughts and had some intention of acting on them?:

{In the past month have you had these thoughts and had some intention of acting on them?:300.0}

In the past month have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?:

{In the past month have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?:301.0}

In the past month have you ever done anything, started to do anything, or prepared to do anything to end your life?:

{In the past month have you ever done anything, started to do anything, or prepared to do anything to end your life?:302.0}

Was this within the past three months?:

{Was this within the past three months?:303.0}

Ever hospitalized for safety?:

{Ever hospitalized for safety?:39.1}

Brief details:

{Brief details:42}

Do you think that you have any learning disabilities?:

{Do you think that you have any learning disabilities?:43.1}

Would you like to conduct a learning assessment at Rise Well Behavioral?:

{Would you like to conduct a learning assessment at Rise Well Behavioral?:44.1}

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Current Providers

Primary Care Provider

Do you have a Primary Care Physician?:

{Do you have a Primary Care Physician?:47.1}

Who is your Primary Care Provider?:

{Who is your Primary Care Provider?:48}

When was your last visit to your Primary Care Provider?:

{When was your last visit to your Primary Care Provider?:49}

When was your last Health & Physical?:

{When was your last Health & Physical?:50}

Do you need help finding a Primary Care Provider?:

{Do you need help finding a Primary Care Provider?:52.1}

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Psychotherapist

Do you have a Psychotherapist?:

{Do you have a Psychotherapist?:54.1}

Who is your Psychotherapist?:

{Who is your Psychotherapist?:55}

When was your last visit to your Psychotherapist?:

{When was your last visit to your Psychotherapist?:56}

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Psychologist

Do you have a Psychologist?:

{Do you have a Psychologist?:59.1}

Who is your Psychologist?:

{Who is your Psychologist?:60}

When was your last visit to your Psychologist?:

{When was your last visit to your Psychologist?:61}

Would you be interested in exploring Psychology services at Rise Well Behavioral?:

{Would you be interested in exploring Psychology services at Rise Well Behavioral?:62.0}

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Current Medical State - Stressors

Do you have Current Stressors?:

{Do you have Current Stressors?:65.1}

Please Describe:

{Please Describe::66}

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Treatment Goal

What is your short-term treatment goal?:

{What is your short-term treatment goal?::68}

What is your long-term treatment goal?:

{What is your long-term treatment goal?:69}

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Symptoms

Do you have Current Symptoms?:

{Do you have Current Symptoms?:71.1}

Please Describe:

{Please Describe:72}

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Medical History

Have you had any medical diagnoses (seizures disorders, diabetes, heart problems, other)?:

{Have you had any medical diagnoses (seizures disorders, diabetes, heart problems, other)?:74.0}

Please list medical diagnoses:

{Label:276}

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Surgical History

Have you had any surgeries in the past?:

{Have you had any surgeries in the past?:81.1}

Please list surgeries:

{Label:280}

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Family Medical History

Do you have biological family members with a medical history of seizures, disorders, diabetes, heart problems, or other conditions?:

{Do you have biological family members with a medical history of seizures, disorders, diabetes, heart problems, or other conditions?:86.1}

For each affected family member, please provide the following information: your relationship to them, whether they are alive, their age of onset for the condition, and their diagnosis.:

{Label:283}

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Family Psychiatric History

Do you have any biological family members with psychiatric history?:

{Do you have any biological family members with psychiatric history?:114.1}

For each affected family member, please provide the following information: your relationship to them, whether they are alive, their age of onset for the condition, and their diagnosis.:

{Label:290}

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Psychiatric History <> Psychiatric Diagnoses

Have you been diagnosed with any psychiatric disorders?:

{Have you been diagnosed with any psychiatric disorders?:105.1}

Any psychiatric disorders:

{Label:286}

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Psychiatric Hospitalizations and/or Rehabilitation

Have you been hospitalized with psychiatric disorders and/or attended rehabilitation facilities?:

{Have you been hospitalized with psychiatric disorders and/or attended rehabilitation facilities?:109.1}

What is the name of the hospital or rehabilitation facility?:

{What is the name of the hospital or rehabilitation facility?:111}

When were you hospitalized or attended the rehabilitation facility?:

{When were you hospitalized or attended the rehabilitation facility?:112}

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Trauma, Abuse, Neglect, and Exploitation

Have you experienced any trauma, abuse, neglect, or exploitation?:

{Have you experienced any trauma, abuse, neglect, or exploitation?:133.1}

What have you experienced?:

{What have you experienced?:134.1}

Please Explain:

{Please Explain:135}

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Previous Substance Use

Were you involved in Substance Use?:

{Were you involved in Substance Use?:137.1}

What were the names of the substance(s)?:

{What were the names of the substance(s)?:139}

How did you acquire these substance(s)?:

{How did you acquire these substance(s)?:140}

What was the peak frequency of your usage for each substance?:

{What was the peak frequency of your usage for each substance?:142.2}

What route was the substance taken?:

{What route was the substance taken?:143}

What age did you start using?:

{What age did you start using?:144}

What age did you stop using?:

{What age did you stop using?:145}

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Current Substance Use

Are you currently involved in Substance Use?:

{Are you currently involved in Substance Use?:147.1}

What were the names of the substance(s)?:

{What were the names of the substance(s)?:148}

How did you acquire these substance(s)?:

{How did you acquire these substance(s)?:149}

What is your current pattern of use?:

{What is your current pattern of use?:150}

What is the peak frequency of your usage for each substance?:

{What is the peak frequency of your usage for each substance?:152.2}

What route are the substance(s) taken?:

{What route are the substance(s) taken?:153}

What age did you start using?:

{What age did you start using?:154}

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Psychiatric Medications

Have you previously been prescribed any Psychiatric Medications?:

{Have you previously been prescribed any Psychiatric Medications?:157.1}

What were the names of the medication(s)?:

{What were the names of the medication(s)?:158}

What were the doses of the medication(s)?:

{What were the doses of the medication(s)?:159}

When did you start taking the medication(s)?:

{When did you start taking the medication(s)?:160}

When did you stop taking the medication(s)?:

{When did you stop taking the medication(s)?:161}

What side effects did you experience from the medication(s)?:

{What side effects did you experience from the medication(s)?:162}

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Non-Psychiatric Medications

Have you previously been prescribed any Non-Psychiatric Medications?:

{Have you previously been prescribed any Non-Psychiatric Medications?:164.1}

What were the names of the medication(s)?:

{What were the names of the medication(s)?:166}

What were the doses of the medication(s)?:

{What were the doses of the medication(s)?:167}

When did you start taking the medication(s)?:

{When did you start taking the medication(s)?:168}

When did you stop taking the medication(s)?:

{When did you stop taking the medication(s)?:169}

What side effects did you experience from the medication(s)?:

{What side effects did you experience from the medication(s)?:170}

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Medication Allergies

Do you have any Medication Allergies?:

{Do you have any Medication Allergies?:172.1}

What is the name of the medication(s) you are allergic to?:

{What is the name of the medication(s) you are allergic to?:173}

What were the reaction(s) you experienced?:

{What were the reaction(s) you experienced?:174}

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Pharmacy

Do you have Pharmac(ies)?:

{Do you have Pharmac(ies)?:176.1}

What are the names of the pharmac(ies)?:

{What are the names of the pharmac(ies)?:177}

In which cities are the pharmac(ies) located?:

{In which cities are the pharmac(ies) located?:179}

In which state(s) are the pharmac(ies) located?:

{In which state(s) are the pharmac(ies) located?:180}

What are the phone numbers of the pharmac(ies)?:

{What are the phone numbers of the pharmac(ies)?:181}

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Legal History Convictions

Do you have a Current or Previous Conviction?:

{Do you have a Current or Previous Conviction?:183.1}

What were the arrest date(s)?:

{What were the arrest date(s)?:184}

What were the charge(s)?:

{What were the charge(s)?:185}

Were you convicted?:

{Were you convicted?:186}

What were the sentence(s)?:

{What were the sentence(s)?:187}

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Probation

Are you currently on Probation?:

{Are you currently on Probation?:189.1}

Are you also on parole?:

{Are you also on parole?:190}

What is the ending date of your probation?:

{What is the ending date of your probation?:191}

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Lawsuits

Are you involved in any lawsuits?:

{Are you involved in any lawsuits?:193.1}

Please explain below:

{Please explain below:194}

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Court Dates

Do you have any upcoming Court Dates?:

{Do you have any upcoming Court Dates?:197.1}

What are the reasons for your upcoming court dates?:

{What are the reasons for your upcoming court dates?:199}

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Resources Dependent Care Resources

Do you need resources for the care of your dependents?:

{Do you need resources for the care of your dependents?:200.1}

please explain below:

{please explain below:202}

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Psychiatric Advance Directive

Do you have a Psychiatric Advance Directive?:

{Do you have a Psychiatric Advance Directive?:204.1}

Please provide a copy of it to the front desk to be scanned into your chart when you hand them this form:

{please provide a copy of it to the front desk to be scanned into your chart when you hand them this form:205}

If you do not have a Psychiatric Advance Directive?, would you like to create one?:

{If you do not have a Psychiatric Advance Directive?, would you like to create one?:206.1}

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Legal Need Resources

Do you need vocational assistance or support?:

{Do you need vocational assistance or support?:210.1}

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Vocational Need Resources

Are you in need of legal assistance or support?:

{Are you in need of legal assistance or support?:208.1}

{I have reviewed and accept Rise Well Behavioral's Practice Policy (View Policy):310.1} I have reviewed and accept Rise Well Behavioral's Practice Policy (View Policy)

{I have reviewed and accept Rise Well Behavioral's Patient Financial Policy (View Policy):311.1} I have reviewed and accept Rise Well Behavioral's Patient Financial Policy (View Policy)

{I confirm that I have reviewed, understand and accept Rise Well Behavioral's Notice of Privacy Practices (View Policy):312.1} I confirm that I have reviewed, understand and accept Rise Well Behavioral's Notice of Privacy Practices (View Policy)

{I have reviewed and accept Rise Well Behavioral's Telemedicine Policy (View Policy):313.1} I have reviewed and accept Rise Well Behavioral's Telemedicine Policy (View Policy)

{I have reviewed and accept Rise Well Behavioral's Patient Medication Acknowledgement Policy (View Policy):314.1} I have reviewed and accept Rise Well Behavioral's Patient Medication Acknowledgement Policy (View Policy)

{I have reviewed and accept Rise Well Behavioral's Appointment Cancellation, Rescheduling and No-show Policy (View Policy):315.1} I have reviewed and accept Rise Well Behavioral's Appointment Cancellation, Rescheduling and No-show Policy (View Policy)

Signature of Patient or Responsible Party (if minor Patient)*

Signature of Patient Representative (If Applicable)

Registration

Basic Patient Information

Patient Health Questionnaire(PHQ-9)

Suicidal Ideations (CCSR)

Immediate Steps for Your Safety

Symptoms

Current Medical State - Stressors

Treatment Goal

Current Providers

Psychotherapist

Psychologist

Medical History

Medical History Listing

Surgical History

Section Break

Section Break

Family Medical History

Section Break

Family Psychiatric History

Section Break

Psychiatric History <> Psychiatric Diagnoses

Section Break

Psychiatric Hospitalizations and/or Rehabilitation

Trauma, Abuse, Neglect, and Exploitation

Section Break

Previous Substance Use

Current Substance Use

Psychiatric Medications

Non-Psychiatric Medications

Medication Allergies

Pharmacy

Legal History Convictions

Probation

Lawsuits

Court Dates

Resources Dependent Care Resources

Psychiatric Advance Directive

Legal Need Resources

Vocational Need Resources

Basic Patient Information

Patient Health Questionnaire(PHQ-9)

Suicidal Ideations (CCSR)

Current Providers

Primary Care Provider

Psychotherapist

Psychologist

Current Medical State - Stressors

Treatment Goal

Symptoms

Medical History

Surgical History

Family Medical History

Family Psychiatric History

Psychiatric History <> Psychiatric Diagnoses

Psychiatric Hospitalizations and/or Rehabilitation

Trauma, Abuse, Neglect, and Exploitation

Previous Substance Use

Current Substance Use

Psychiatric Medications

Non-Psychiatric Medications

Medication Allergies

Pharmacy

Legal History Convictions

Probation

Lawsuits

Court Dates

Resources Dependent Care Resources

Psychiatric Advance Directive

Legal Need Resources

Vocational Need Resources