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Patient Information

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Name:
Address:
Telephone: Work: Cell:
Date of Birth: SS#:
Age:
Sex:
Female
Male
   
Married
Single
Divorced
Widowed
Separated
 
Domestic Partnership
Patient Occupation:
Employer:

Spouse/Partner Name:
Date of Birth:
Spouse/Partner SS#:
Spouse/Partner Employer:

Responsible Party: Employer:
SS#: Address:

Pt. Family Doctor:
Phone:
Address:

Referred By: Phone:

Emergency contact other than spouse/partner:
Phone:

I request payment of authorized insurance benefits, including Medicare/Medicare supplements, be made on my behalf to MBHC, INC. for any services furnished to me.  I authorize the release of any medical information needed to determine payment of insurance claims.  A photocopy of this form shall be considered as effective and valid as the original.  I agree to MBHC’s rescheduling and cancellations policy stating all appointments must be changed or cancelled within 24 hours or I will be responsible any fees incurred.  All balances must be paid within 120 days unless other arrangements have been made.

The office staff will attempt to give you a reminder call the day before your appointment. Please let them know if you do not wish to have one. 
All co-pays are due at time of service.  I understand I am fully liable for any balance not paid by insurance.
                                                       

Patient Information    
New Patient History    
     
       
           

New Patient History

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Name:
Reason for visit:
Have you been in therapy before or received any professional assistance for you problem?
Yes No  
If so, by whom?
Have you ever been hospitalized for psychological/psychiatric problems?
Yes No  
If so when: (Dates)
Where?
Education: :
Employment (Past and present):
     
List any medical illness(es) you now have:
Present Medication:
                     
 
Do you have any allergies? Yes No    
What?
 
Have you or are you now considering harming yourself?
 
Have you or are you now considering harming someone else?
 
Do you have any relative(s) who suffer from medical/emotional problems?
 
If so, please explain:
 
What would you like to achieve from therapy?
 
   
Date:
                                   
       
 
InnerView Behavioral Care
MBHC Inc.
27475 Holiday Lane Suite 2
Perrysburg, OH 43551

Tel: 419-872-0619
Fax: 419-872-2466