TeleMental Health Clinical Record

Initial Information For

privacy#:

Client Name:

DOB:

Sex:

M _F:

Address:

City/State/Zip:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

Emergency Contact:

Contact Phone:

Client is:

Married:

Single:

Other:

Employed:

Full-time Student

Part-time Student

Insurance Information

Insurance Plan:

Insurance ID#:

Insurance Group#:

Insured’sEmployer:

Client’s relationshipto insured:

Self*

Spouse

Child _Other:

*If you checked “Self” above, leave these blank

*Address: *City/State/Zip: Is there a second insurance plan? Yes No If yes, fill out information below for second insurance plan Insurance Plan Insurance ID#: Insurance Group#: Insured’s Employer: Insured’s Name: Insured’s DOB: Address:City/State/Zip: b Please list other providers of health and mental health services

Primary Care Physician (PCP):

Address: Suite Number:

City, State, Zip: Phone:

Psychiatrist(if any):

Address:

Suite Number:

City, State, Zip:

Phone:

Other counselor (if any): Address: Suite Number: City, State, Zip: Phone:

Local Resources:

Primary Contact person: Address: City, State, Zip: Email Phone: Relationship to client:_

Comments:

Back-up Contact person:

Address:

City, State, Zip:

Email:

Phone:

Relationship to client:

Comments:

Local Counseling resource:

Address:

City, State, Zip:

Email:

Phone:

Comments:

Back-up Counseling resource:

Address:

City, State, Zip:

Email:

Phone:

Comments:

Local Police Dept:

Phone number:

Nearest Hospital Emergency Room:

Address:

City, State, Zip:

Email:

Phone:

Comments:

Nearest Psychiatric Hospital: Address: City, State, Zip: Email Phone:

Comments:

Local DFACS Office Phone number:

Other contact (list):

Phone#:

Describe:

Comments: