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Current Mental Health Provider:
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Is This Your Legal Name
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If Not What Is Your Legal Name?
If Not What Is Your Legal Name?
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Former Name
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Date of Birth:
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Cell
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Email
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Chose clinic because/Referred to clinic by (please check one box):
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Person Responsible for Bill:
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Birth Date:
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Address (if different):
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Primary Insurance:
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Co Pay:
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Name of secondary insurance (if applicable):
Name of secondary insurance (if applicable):
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Subscriber’s name:
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Group No:
Group No:
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Policy Number:
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Name of local friend or relative:
Name of local friend or relative:
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Therapist Name:
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Relationship to patient:
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Home Phone:
Home Phone:
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Work Phone:
Work Phone:
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The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize CARING HANDS MEDICAL CLINIC, LLC or insurance company to release any information required to process my claims.
Patient/Guardian signature:
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Date:
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Please list any PREVIOUS and CURRENT medical problems:
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Please list all past SURGERIES:
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Please list all CURRENT MEDICATIONS including over the counter medications:
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Please list all FOOD and DRUG allergies:
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Please list your FAMILY MEDICAL HISTORY:
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Social History

Do you Smoke?
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How many cigarettes a day?
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# of years smoking?
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Do you drink caffeine?
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How much?
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Do you drink alcohol?
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How Often?
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what kind of liquor?
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Have you ever used illicit drugs?
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What Kind?
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Are you sexually active?
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Do you exercise?
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How Often?
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What type of exercise?
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Do you eat out at restaurants?
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How Often?
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How many servings of fruits and vegetables do you eat per day?
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Do you take calcium supplements?
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How may dairy servings per day?
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Is there any concern for your safety at home?
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Physical / Emotional / or Sexual abuse?
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MENTAL ASSESSMENT

Family History of Psychiatric Illness and/or Substance Abuse:
Current Family System/Home Environment:
Social History: To understand you better, tell me more about the following
Your reason for seeking mental health care
Childhood trauma?
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Illegal/legal drugs/alcohol use Type?
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  • Marijuana/weed
  • Cocaine
  • PCP
  • K2
  • Molly
  • AMphetamine
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Jail status?
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Any custody / child support issues?
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History of Physical/Sexual Abuse?
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Financial status/assistance
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Living condition?
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Place of Birth?
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Family/adoption? Siblings: Both Parents alive
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Career/ profession/job status?
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Childhood experience?
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Truancy /stealing/robbery:
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Homelessness/shelter
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Future wishes:
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Strengths/good things about you
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Weaknesses/bad things about you that you make you unhappy
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History of Out-of-Home Placement
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Developmental History : Do you think you met all your social, emotional, cognitive, motor, language and self-care needs/ milestones?
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Additional social issues : Do you or have you had any history of these problems?

Legal System involvement issues:
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Problems in Family Relations
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Problems in Friendships/Social Relations:
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Legal Issues?
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SchoolWork_Problems?
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Custody/Placement Issues?
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Financial_difficulties?
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Problem in Living situation?
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Physical and Sexual Abuse history?
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Physical Health conditions?
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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
Patient First Name
Patient First Name
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Last Name
Last Name
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Patient Signature
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