Revised Website New Patient Form

New Patient Information
Which Heartland office is your appointment in? *

Urbandale Pella
Name
Phone
Cell
Address

Street Address

Street Address Line 2

City

Zip Code
Birth date

Month Day Year
Date
Sex

Male Female
Marital Status

Single Married Widow/Widower
Email address
example@example.com
Did anyone refer you to Heartland? If yes, who?
Insurance Provider
ID #
Group #
Policy Holder
DOB
Policy Holder's employer
Secondary Insurance Provider
ID#
Group #
Policy Holder
DOB
Policy Holder's employer
Primary Care Physician
Phone
Address
Other Physician (i.e. Psychiatrist)
Phone
Address
Emergency Contact
Phone
Relationship
Alternate Phone
Address
Please fill out to the best of your ability:
Reason for Therapy
Goals for Therapy
History of Present Problem
Any Past Counseling and/or Psychiatric History
Any Trauma History
Any Past Psychiatric History of Family Members
Medical Conditions and History
Current Medication, Date Started, Purpose, Dose, Physician who prescribed it
1.
2.
3.
4.
5.
6.
Any Substance Use/Abuse History
Educational/Occupationa History
Any Legal Problems
What are your Strengths?
What are your Weaknesses?
Additional Comments
Patient/Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Should be Empty:

New Patient Information