Person Completing Form

Insurance Company

Insured Party

Services:

Please tell us what services you would like us to check for.

IOP
Individual
Mental Health
Substance Abuse
Sex Addiction
Eating Disorders
Psychiatrist

Client Information

Alcohol/Drug Treatment History

Did you complete the
treatment program?

Current Medications

List all surgeries you have had including elective and cosmetic surgeries:

Drug(s) of Choice & Usage Patterns

Medical & Psychiatric Information

Have you ever had a problem with gambling? Yes No
Do you currently gamble? Yes No
Have you ever had an eating issue or eating disorder? Yes No
What do you struggle with most in a relationship?
Have you ever had a problem with intimacy or relationship issues? Yes No
Do you feel that your sexual behavior is or has ever been a problem? Yes No

Sexual History:
Are your sexually active? Yes No
Sexual Orientation: Heterosexual Homosexual Bisexual Transsexual Asexual

Buy Big Purchases:
Do you overspend or buy ticket purchases, and feel remorseful later? Yes No
Do you often make purchases only to return them? Yes No
Do you shop to "feel better"? Yes No

Criminal History:
Have you ever been arrested? Yes No
If YES, please explain giving date of arrest, reason for arrest and outcome:
Do you have any current legal issues? Yes No

Medical History & Hospitalization

Medical Emergencies (Seizures, Stop Breathing, Blackouts, Tramatic Brain Injury):
Yes No - If Yes, Please Explain:

Miscarriages, Abortions, Adoptions: Yes No
If Yes, Please Explain:

What is your current living situation?

Current Marital Status: Single Married Divorced Seperated Widowed

If Divorced, how many times: Explain:

Do you have any children? Yes No
If Yes, how many and what are their ages?

Any custody issues? Yes No - If Yes, Please Explain:

Education / Job Training:

Highest Degree Obtained:

Military Experience: Yes No - If Yes, Please Explain:

Learning, Reading, or Writing Deficits:

Are you currently employed? Yes No - If No, Why Not?

If currently unemployed, for how long have you been unemployed?

If you are employed, where are you employed?

Is your job in jeopardy due to your behavior or issues? Yes No

Is your employer aware that you have a problem? Yes No

Have you been experiencing any job or school difficulties? Yes No
If Yes, Please Explain:

• Advanced Health Systems (AHS)
• Aetna
• Blue Cross Blue Shield of Mississippi
• Blue Cross Blue Shield Out of State Plans
• Cigna Behavioral Health
• ComPsych
• First Choice Health Plan of Mississippi
• First Health
• Galaxy Health Network

• GEHA
• Life Synch
• Magellan Behavioral Health
• Mississippi Physicians Care Network
• PPOUSA
• Three Rivers Provider Network
• United Behavioral Health (UBH)
• USA Managed Care Network
• Value Options

YOUR INFORMATION (not necessarily the prospective patient)

IOP
Individual
Mental Health
Substance Abuse

PROSPECTIVE PATIENT

INSURANCE COMPANY

INSURED PARTY