Healing House - Patient Intake Form (V1.2)

Thank you for allowing us to be part of your care journey. We are honored to be entrusted with your care. Please take a moment to fill out this form; it helps us better understand your unique needs and how we can provide the care that best serves you.

Black/African/African-American

Latino

Pacific Islander

Asian

White

Decline to identify

American Indian/Alaska Native/Native Hawaiian/Enrolled Citizen- please list tribe below

Prefer to self describe- please type in below

Insurer

Policy Name

Policy / Group / Plan #

Member ID / Certificate #

Policy Holder

I'm not the policy holder.

First Name

Last Name

Relationship To Patient

Date of Birth

Address

City

Prov / State

Postal / Zip Code

Phone Number

Can we support you with referrals to community programs and resources? We can share information about organizations that help with things such as transportation, housing, and food. 

Please describe if there any accommodations our clinic can make for you (for example, magnifying glasses if you are visually impaired, assistance with forms, dimming fluorescent lighting, etc.):  

Are you currently taking any other prescription medications, over-the-counter medications, vitamins or other nutritional/herbal supplements?

Yes

Hospitalizations. When and why?

Surgeries. When and why?

Accidents or Injuries? When and what?

Do you currently have or have you had in the past, any of the following?

No to all

Yes- please select all that apply

Do you currently or have had in the past 6 months, any of the following symptoms/conditions?

No to all

Yes - please check below

Have any of your family members had: (GP=Grandparent, P=Parent, S=Sibling, C=Child)

No to all

Yes- please select all that apply

Many families are having a hard time. Are there additional life stressors on your family? Please check below if so.

Housing

Food

Legal/court system

Racial discrimination

Domestic violence

Employment

Medical issues in the family

Other

Tubman Center for Health & Freedom Information and Consent for Care (Review Required)

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Tubman Center for Health & Freedom No Call No Show Policy (Review Required)

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Tubman Center for Health & Freedom Release of Records for Treatment and Coordination of Care (Review Required)

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HIPAA Notice of Privacy Practices (Review Required)

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