Medication Management Intake Form

The form will help ensure that the necessary information is provided for your client’s medication management.

Referral Date *

Name of Doctor *

Insurance Information:

Insurance Type *

Medicaid

Medicare

Private Insurance

Self-pay

Insurance Name *

Insurance Number *

Doctor Contact Number

Date of birth *

Client Information:

First Name *

Last Name *

MA# *

Address

Street Address *

City

State

Country

Postal code

Phone *

Work Phone

Client Age *

Gender: *

Height

Weight

Marital Status

Single

Married

Religion: *

For clients under 18 years of age

Parent/Guardian Name *

Relationship *

Parent/Guardian Telephone Number *

Parent/Guardian E-mail Address

Emergency Contact Information

Emergency Contact: *

Emergency Contact Telephone #: *

Emergency Contact Relationship to the client *

Referring Therapist Information

Therapist Name/Credential: *

Company Name:

Therapist Phone Number *

Therapist E-mail Address *

Diagnosis *

Brief Summary of Client's Condition: *

History of Medication Use (if applicable):

Other Important Observations:

Living Arrangements

Who do you live with?

Employment Information

On sick leave, as of this date:

Return to work date:

Employment Status

Employed

Self-employed

Unemployed

Employer Name:

Position:

Academic Information

School Status

At School Full-time

At School Part time

Not attending school

Name of Student's School

Current grade level:

Highest school level completed?

Typical Grades

Section II Medical History:

Family Health History

Mother

Mother's Current age

Mother's Mental Health Diagnosis, Symptoms, Substance Abuse, Mood, Sleeping

Mother's Age at Death

Mother's Cause of Death

Father

Father's Current Age

Father's Mental Health Diagnosis, Symptoms, Substance Abuse, Mood, Sleeping

Father's Age at Death

Father's Cause of Death

Siblings

Sibling 1 Current Age

Sibling 1 Gender

Sibling 1 Mental Health Diagnosis, Symptoms, Substance Abuse, Mood, Sleeping

Sibling 1 Age at Death

Sibling 1 Cause of Death

Sibling 2 Current Age

Sibling 2 Gender

Sibling 2 Mental Health Diagnosis, Symptoms, Substance Abuse, Mood, Sleeping

Sibling 2 Age at Death

Sibling 2 Cause of Death

Sibling 3 Current Age

Sibling 3 Gender

Sibling 3 Mental Health Diagnosis, Symptoms, Substance Abuse, Mood, Sleeping

Sibling 3 Age at Death

Sibling 3 Cause of Death

Children

Child 1 Current age

Child 1 Gender

Child 1 Mental Health Diagnosis, Symptoms, Substance Abuse, Mood, Sleeping

Child 1 Age at Death

Child 1 Cause of Death

Child 2 Current Age

Child 2 Gender

Child 2 Mental Health Diagnosis, Symptoms, Substance Abuse, Mood, Sleeping

Child 2 Age at Death

Child 2 Cause of Death

Child 3 Current age

Child 3 Gender

Child 3 Mental Health Diagnosis, Symptoms, Substance Abuse, Mood, Sleeping

Child 3 Age at Death

Child 3 Cause of Death

Previous medical history other than reason for being here. Include significant illnesses, hospitalizations and injuries.

Problem & Treatment:

Where & Dates Treated:

Treating Physician:

Have you ever been admitted for an inclient stay for a mental health condition: *

Yes

No

If you have indicated Yes, please provide the following admission details. Where you were admitted, diagnosis, admission dates & results.

Section III Medications

Please list all medications you are now taking or have taken in the past three months.

Medication 1 *

Medication 1 Strength *

Medication 1 Average in 24hrs *

Medication 1 Maximum in 24hrs *

Medication 1 Prescribing M.D. *

How many months were you on medication 1? *

Was medication 1 beneficial? Please indicate Yes or No *

Medication 2 *

Medication 2 Strength *

Medication 2 Average in 24hrs *

Medication 2 Maximum in 24hrs *

Medication 2 Prescribing M.D. *

How many moths were you on medication 2? *

Was medication 2 beneficial? Please indicate Yes or No *

Medication 3 *

Medication 3 Strength *

Medication 3 Average in 24hrs *

Medication 3 Maximum in 24hrs *

Medication 3 Prescribing M.D. *

How many months were you medication 3? *

Was medication 3 beneficial? Please indicate Yes or No *

Medication 4 *

Medication 4 Strength *

Medication 4 Average in 24hrs *

Medication 4 Maximum in 24hrs *

Medication 4 Prescribing M.D. *

How many months were you on medication4? *

Was medication 4 beneficial? Please indicate Yes or No *

Medication 5 *

Medication 5 Strength *

Medication 5 Average in 24hrs *

Medication 5 Maximum in 24hrs *

Medication 5 Prescribing M.D. *

How many months were you on medication 5? *

Was medication 5 beneficial? Please indicate Yes or No *

Please provide additional medication information below. *

Medications to which you are allergic: *

Please list any side effects or reactions to any of the above checked medications. Also specify which medication caused each reported reaction. *

Please provide the start date, last use date & amount used per day along with the corresponding substance. *

Sleep Study:

Please indicate Yes or No to the following sleepy study questions. *

Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
Do you often feel tired, fatigued, or sleepy during the daytime?
Has anyone observed you stop breathing during your sleep?
Do you have or are you being treated for high blood pressure?

Is there any additional information?

Provide 3 days and times that you are available. *

Signature *

Clear

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