Please complete the form below and send to us prior to your appointment. This is your new patient intake packet and will be sent directly to our Practice Manager Moriah Schultz, RN. You will not be seen without a new patient packet

Purpose of this questionnaire

This questionnaire was developed to obtain a comprehensive picture of you and your background. Your responses, combined with information discussed with your therapist/physician, lead to an assessment of you and your concerns. This will allow us to develop a plan to meet your needs and goals. As you can see the completeness of your responses is valuable to your therapy program.

All information obtained and submitted is strictly confidential. Your responses will be attached to your electronic medical record through our secured health link portal. Great Lakes TTC, LLC. complies with all state and federal guidelines regarding protected health information. This template will not allow you to save information and return to complete at a later time for security purposes. Please feel free to call with any additional questions.











Identification
Insurance Information
Household Information
For the following people, please provide the name, age (including DOB), relationship (full, half, step, adopted), marital status, where are they living, their occupation, and history of emotional disorder or substance abuse, if applicable.
Referral
Medication & Allergies
Family History






















Medical History



































Psychiatric History


























Social History
Military History
Legal History
Educational Background
Marital / Relationship History
Early Development

















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