New Patient Appointment Request - Relief Mental Health

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Intake form

NEW PATIENT APPOINTMENT REQUEST

Thank you for your interest in Relief Mental Health! If you are interested in any of our services, please complete and submit the following form, and a member of our intake team will reach out to you within 24 business hours to schedule an initial consultation, as long as your care falls within our scope of practice. While our expertise is broad, there are certain mental health diagnoses that fall outside our scope of practice. We cannot guarantee patients will be scheduled for services after completing and submitting this form, nor will initial consultations guarantee a continued patient-provider relationship.

We appreciate your trust in us and value the opportunity to support you on your mental health journey and help you find relief.

WHICH SERVICE(S) ARE YOU INTERESTED IN?

Psychiatric Medication Management

Talk Therapy

TMS

SPRAVATO®

IV Ketamine

PREFERRED CLINIC

Oak Brook, IL

Northbrook, IL

St. Charles, IL

Orland Park, IL

Chicago Lakeview, IL

Chicago West Loop, IL

Rockford, IL

West Allis, WI

Red Bank, NJ

Warren, NJ

PATIENT CONTACT INFORMATION

Patient Name (as it appears on insurance card)

Preferred Name

Gender

Pronouns

DOB

Patient Phone

Patient Email

Address

City

State

Zip Code

Name of person completing form (if different than patient)

Relationship to patient

Phone

PRIMARY INSURANCE INFORMATION

Insurance Provider

ID #

Type of Policy

PPO

HMO

EPO

POS

Federal

Labor Union

Medicare

Medicare Replacement

Medicare/Medicaid (OON)

Medicaid (OON)

Other

Insurance Phone

Group #

Name of Subscriber (if different than patient)

Subscriber Relationship

Subscriber DOB

Subscriber’s Employer (if insured through employer)

SECONDARY INSURANCE INFORMATION

N/A

Insurance Provider

ID #

Name of Subscriber (if different than patient):

Insurance Phone

Group #:

Subscriber Relationship

Subscriber DOB

PATIENT INTAKE

How did you hear about Relief Mental Health? Who referred you?

Are you seeking treatment to obtain short- or long-term disability or FMLA?

Yes

No

We cannot guarantee that our providers will sign off on any disability or FMLA paperwork; it will be at the discretion of the treating provider.

What is your primary diagnosis or reason for seeking treatment?

What mental health diagnoses do you have? Check all that apply.

Depression

When were you diagnosed? (MM/DD/YY)

What mental health diagnoses do you have? Check all that apply.

OCD

When were you diagnosed? (MM/DD/YY)

What mental health diagnoses do you have? Check all that apply.

Anxiety

When were you diagnosed? (MM/DD/YY)

What mental health diagnoses do you have? Check all that apply.

ADHD

When were you diagnosed? (MM/DD/YY)

What mental health diagnoses do you have? Check all that apply.

Eating disorder

When were you diagnosed? (MM/DD/YY)

What mental health diagnoses do you have? Check all that apply.

Bipolar/mood disorder

When were you diagnosed? (MM/DD/YY)

What mental health diagnoses do you have? Check all that apply.

PTSD

When were you diagnosed? (MM/DD/YY)

What mental health diagnoses do you have? Check all that apply.

Personality disorders

When were you diagnosed? (MM/DD/YY)

What mental health diagnoses do you have? Check all that apply.

Autism spectrum or other neurological disorders

When were you diagnosed? (MM/DD/YY)

What mental health diagnoses do you have? Check all that apply.

Schizophrenia spectrum or other psychotic disorders

When were you diagnosed? (MM/DD/YY)

What mental health diagnoses do you have? Check all that apply.

Other

Other (please specify)

When were you diagnosed? (MM/DD/YY)

What mental health diagnoses do you have? Check all that apply.

No prior diagnosis

Do you have a recent history of substance or alcohol use disorder?

Yes

No

If yes and you are currently sober, how long have you been sober?

Have you ever seen a psychiatrist?

Yes

No

Psychiatrist/practice name

If requesting medication management services: What is the reason for switching providers?

Have you ever seen a therapist or counselor?

Yes

No

Therapist/practice name

Start/stop dates

Frequency of sessions

Have you been hospitalized for your mental health within the past 3 years (i.e. ER visit, inpatient stay, residential program, PHP, IOP, etc.)?

Yes

No

If yes, when and where were you hospitalized? Specify level of care.

Have you ever attempted suicide?

Yes

No

If yes, when was your most recent attempt?

Have you ever had thoughts of harming yourself or others?

Yes (yourself)

Yes (others)

Yes (yourself and others)

No

If yes, have you ever acted on those thoughts?

Yes

No

Are you seeking treatment for a court-mandated order?

Yes

No

Are you currently pregnant or breastfeeding or planning to become pregnant?

Yes

No

Do you have any other medical conditions or chronic illnesses?

Yes

No

If requesting therapy services: Please provide your preferences and availability below.

Therapist preference

Male

Female

Either

Session preference

In-Person

Virtual

Either

Recurring availability for weekly sessions

What are your current symptoms? What would you like to work on in therapy?

MEDICATION HISTORY

NO PRIOR MEDICATION HISTORY

Please list your current psychiatric medications, as well as any past psychiatric medication trials with approximate dosages, dates of use, and the reason for discontinuation, if applicable.

Current medications, dosage (mg), date prescribed (MM/YY), side effects (if applicable)

Previous medications, dosage (mg), date prescribed (MM/YY), side effects (if applicable)

Phone: (855) 205-4764
Fax: (630) 487-2411
Email: info@reliefmh.com

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Corporate Address:
1100 Jorie Blvd., #300
Oak Brook, IL 60523

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ABOUT
- OUR TEAM
- FOR PROVIDERS
- TESTIMONIALS
- BLOG
- NEWS
- EVENTS
WHAT WE TREAT
TREATMENTS
LOCATIONS
NEW PATIENTS
CONTACT
(855) 205-4764

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