Mental Health Appointment Request Form - Surgical Associates of Grinnell | Surgery and Medicine in Iowa

Mental Health Appointment Request Form

If this is an emergency please contact your local Emergency Room or dial 911.

 

Please complete this form in it’s entirety. Your form will be reviewed and you will be contacted by a member of the Surgical Associates staff.

* denotes a required field.
Client Information
Patient Name: *
Name of parent/guardian:  
(if under 18 years)  
Date of Birth:  
In mm/dd/yyyy format
Age:  
Gender:  
Marital Status:  
Please list any children/age:  
Street Address:  
City:  
State:  
Zip Code:  
Home Phone:  
XXX-XXX-XXXX  
Cell/Other Phone:  
XXX-XXX-XXXX  
Messages may be left on the numbers above:  
Insurance/Policy Information:  
E-mail: *
May we email you:  
Referred by:  
If any  
Have you previously received any type of mental health services:  
psychotherapy, psychiatric services, etc.  
If yes, please list therapist/practitioner:  
Are you currently taking any prescription medication:  
If yes, please list medication and prescriber:  
General Health and Mental Health Information
Rate your current physical health:  
Please list any specific health problems:  
Rate your current sleeping habits:  
Please list any specific sleep problems:  
Number of times you generally exercise per week:  
List the types of exercise you participate in:  
Please list any difficulties you experience with your appetite or eating patterns:  
Are you currently experiencing overwhelming sadness, grief, or depression:  
If yes, for approximately how long:  
Are you currently experiencing anxiety, panic attacks, or have any phobias:  
If yes, when did you begin experiencing this:  
Are you currently experiencing any chronic pain:  
If yes, please describe:  
Do you drink alcohol more than once per week:  
How often do you engage in recreational drug use:  
Please list any significant life changes or stressful events you have experienced recently:  
Additional Information
Are you currently employed:  
If yes, please describe your current employment situation:  
Do you enjoy your work? Please list anything you find stressful about your current work:  
Do you consider yourself to be spiritual or religious:  
If yes, please describe your faith or belief:  
Please list what you consider to be some of your strengths:  
Please list what you consider to be some of your weaknesses:  
Please describe what you would like to accomplish out of your time in therapy:  
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