Registration

Please fill in the information with the most accurate details. It allows us to provide the best medical care possible.

- Step 1 of 6

Date *

PCP

Current Psychiatrist

Therapist

PATIENT DETAILS

Patient Name *

First

Middle

Last

Mr. / Mrs. / Ms

Marital status

Email *

Phone no.

Birth date *

Age

Sex *

SSN

Street Address

Address Line 1

Address Line 2

City

State

Zip Code

Occupation

Employer

Phone Number

Person Responsible for bill *

First

Last

Birth Date

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Insurance

Policy Number

Group Number

Co-Pay $

Patient's relationship to subscriber

Self
Spouse
Child
Other

Name of secondary insurance (if applicable)

Policy Number

Group Number

Preferred Pharmacy

please include Phone

IN CASE OF EMERGENCY

Name of local friend or relative: *

First

Last

Relationship to patient

Phone Number

Patient/Guardian Signature

Date

Your reason for seeking mental health care

Please list any PREVIOUS and CURRENT medical problems

Please list all past SURGERIES

Please list all CURRENT MEDICATIONS including over the counter medications.

Please list all FOOD and DRUG allergies

Please list your FAMILY MEDICAL HISTORY

Do you give me permission to manage your condition without doctors shopping?

Do you smoke?

How many cigarettes a day?

Numbers of years smoking?

Do you drink caffeine?

How much?

Do you drink alcohol?

How often?

What kind of liquor?

Have you ever used illicit drugs?

What kind?

Marijuana
Cocaine
PCP
K2
Other Drugs

Your parents living

Father’s name

Mother’s names

Relationship quality

Are married?

Wife’s/husband’s name *

Can we contact your wife/husband in case of an emergency?

Do you have children?

How many?

Does your family have any mental health illness?

Who?

Have experienced any trauma in the past

What type?

Is there any concern for your safety at home?

Do you have siblings?

Birth order

What is your temperament? (e.g easy-going, hot tempered, anxious)

Do you have friends?

How do you describe yourself introvert (not friend) or extroverts (friendly)? Describe

Educational level

Grade
High school
Some college
Associates
Bachelors
Master

Childhood fears/behavior

Accomplished Milestones?

Hospitalization history

Family History of Psychiatric Illness and/or Substance abuse?

Current Family Support System /Home Environment

Any current/history of suicidal/homicidal attempts/ideation?

Current and childhood trauma?

Have you ever been incarcerated?

What was the reason?

Any custody / child support issues?

History of abuse? Physical/ Emotional/ Sexual abuse?

Neglect?

What type of abuse?

Years of abuse

Did you received Treatment ?

Inpatient facility name

Financial status/assistance?

Living condition?

Place of Birth?

Career/ profession/job status?

Childhood experience?

Any history of Truancy /stealing/robbery?

Any history Homelessness/shelter ?

Future wishes

Strengths/good things about you

Weaknesses/bad things about you that you make you unhappy

Any history of Out-Of-Home placement

Developmental history: Do you think you met all your social, emotional, cognitive, motor, language and self-care needs/milestones?

Do you or have you had any history of these problems?

Legal System involvement issues
Problems in Family Relations
Problems in Friendships/Social Relations
Legal Issues?
School/Work Problems?
Custody/Placement Issues?
Financial difficulties?
Problem in Living situation?
Physical Health conditions?

FAMILY HISTORY OF ANY OF THE FOLLOWING:

Please name them below
Diabetes, hypertension, cholesterol, cancer, asthma, kidney disease, coronary artery disease, bleeding disorders, thyroid disorder, respiratory, depression, anxiety, PTSD, schizophrenia, bipolar, personality disorder, substance abuse disorder, or any form of mental illness.

Father’s health status:

Mother’s health status:

CONSENT *

Our office will file claims with your insurance for all services rendered, to BOTH AND SECONDARY insurance carriers. PLEASE REMEMBER THAT YOU ARE RESPONSIBLE FOR ALL DEDUCTIBLE, CO-PAY AND NON- COVERED SERVICE AMOUNTS. Whenever necessary, I authorize Dr. Elizabeth Ndika or Caring Hands Medical Clinic staff members to release any of medical or mental health records/ information necessary to treat me or process my claim. I authorize payment of medical and surgical benefits to Caring Hands Medical Clinic, LLC.

ASSIGNMENT OF BENEFITS *

I hereby assign Dr. Elizabeth Ndika or Caring Hands Medical Clinic staff any insurance or other third-party benefits available for health care services provided to me. I understand that Dr. Elizabeth Ndika has the right to refuse or accept assignment of such benefits.

CONSENT TO TREAT *

I (or my legal guardian or parent) authorize Elizabeth Ndika,DNP,PMHNP-BC, FNP-C to provide mental healthcare reasonable to current evidence based standards. I also consent that l will not use Dr. Nika’s information illegally for the purpose of obtaining treatment not permitted by the provider. I consent to the treatment recommended by Dr. Ndika .I understand that she can discharge me from her care if she deems it necessary and if l violate my treatment recommendations, provider-client trusting relationship, and any of the above terms.

NOTICE OF PRIVACY *

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examinations, test results, diagnosis, treatment and any plans for future care or treatment. I understand that I have the right to object to the use of my health for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

Print Name *

Patient’s/Guardian signature *

Date *

Book An Appoinment

We encourage our patients to ask questions in order to be informed about their medical conditions and treatment plans. This will enable our patients to make better choices about their health and well-being.

Call +1 240 241 4989