Orion Family Services
6333 Odana Road
Madison, WI 53719
Patient Information Form
Date:_________________________________________
Home Phone:__________________________________
Work Phone:__________________________________
Cell Phone:____________________________________
Address:____________________________________City:_______________________________Zip:________________
Name:_____________________________________
Social Security Number:____________________________________________________ Date of Birth:____________
Sex:
M
F
Marital Status: Single___________Married_________________Divorced_____________ Widowed________________
Spouse/Parent:_____________________________________________________ Phone:________________________
Address:______________________________________________City:_________________________Zip:____________
Family Members
Name
D.O.B.
Sex
Relationship
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Occupation:_________________________________
Student:
Full time:_______Part-time:_______
Full time________Part-time:______
Employer:__________________________________
City:_________________________
School____________________________________
Racial Heritage:
_____White
_____African American
_____Asian/Pacific Islander
_____Hispanic
_____Non-Hispanic
_____American Indian/Native Alaskan
_____Other
Referred From: _____Self
_____School
_____Hospital
Education Completed:
_____0-8 years
_____9-12 years
_____G.E.D
_____Tech School
_____Family/Friend
_____Employer
_____Private MD
_____Some College
_____Bachelors Degree
_____Master’s Degree
_____Doctoral Degree
_____Social Service Agency
_____Legal System
_____Other
(over)
Family Physician__________________________________________Date of Last Visit___________________________
Clinic/Physician’s Address________________________________________Phone_______________________________
Current Medications_________________________________________________________________________________
Financially Responsible Person:
Name:____________________________________________________________________________________________
Driver’s License Number______________________________________Relationship to Client______________________
Address____________________________________City__________________________State_________Zip__________
Employer__________________________________________________________________________________________
Employer’s Address_________________________________________________________________________________
I understand that all information given is true and correct.
Signature (Client or Legal
Guardian)_______________________________________________________________Date_______________________
(Legal Guardian Signature required of anyone under age 18)
Health and Personal History
Current Problems: (check all that apply)
___sleep
___appetite
___mood swings
___relationships
___loneliness
___learning
___work problems
___legal trouble
___memory
___blank periods
___spirituality
___pain
___identity
___crying
___concentration
___worry
___weight loss ___weight gain ___panic attacks
___isolating
___anxiety
___thoughts of suicide or homicide
___behavior
___alcohol use ___suicide or homicide attempt
___anger
___drug use
___obsessive thoughts or acts
___stress
___phobia
___social discomfort
___hallucinations___irritability
___frightening thoughts
___other
___loss of interest in usually enjoyable activities
___sexuality
___thoughts or beliefs that you think are unusual
___________________________________________________________________________________________________________
Previous Therapy___________________________________________________________________________________
Health Concerns____________________________________________________________________________________
Current Medications (type and dosage)__________________________________________________________________
Hospitalizations (dates and reason)______________________________________________________________________
Suicide attempts (dates)______________________________________________________________________________
Family history of mental illness________________________________________________________________________
Family history of alcoholism or drug dependence__________________________________________________________
Do you use alcohol?_____
Tobacco?_____
Marijuana?_____
Other drugs_____
Which of the above have you used in the past?____________________________________________________________
Religious affiliation__________________________________________________________________________________
Hobbies, interests___________________________________________________________________________________
Father:
Name______________________________
Occupation_________________________
If deceased, age, year, cause of death_______________________________________________________
Mother:
Name:____________________________
Occupation________________________
If deceased, age, year, cause of death_______________________________________________________
Siblings:___________________________________________________________________________________________
Current Stresses (check all that apply)
_____Family conflicts
_____Relationship breakup
_____Health concerns
_____Changes in my family
_____Rape/assault
_____Abuse during childhood
_____Financial stresses
_____Traumatic experience
_____Starting or ending school
_____Job problems/loss
_____Death of a loved one
_____Other_____________________________
Orion Family Services
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
*You may refuse to sign this acknowledgement*
I,______________________________________________________________________, have received a copy
of Orion Family Services Privacy Practices Notice.
Please Print Patient’s Name
Signature of Patient (or Guardian if Patient is under 18 years of age)
Date
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but
acknowledgement could not be obtained because:
_____Individual refused to sign
_____Communication barriers prohibited obtaining the acknowledgement
_____An emergency situation prevented us from obtaining acknowledgement
_____Other (Please Specify)
__________________________________________________________________________________________