"*" indicates required fields Full Name* Patient's First Name Patient's Middle Initial Patient's Last Name Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact & Personal InformationPhone Number*Email address* Birthday Date MM slash DD slash YYYY GenderMaleFemaleMarital StatusSingleMarriedDivorcedSeparatedYears MarriedYears DivorcedAre you currently in a romantic relationship? Yes No If yes, how long?On a scale of 1-10 how would you rate your relationship?12345678910Social Security Number*Insurance Carrier*As it appears in the insurance cardHow did you find Transcendent Truth, Inc?*How did you find Transcendent Truth, Inc?Last School Grade CompletedName of Current School or Employer*Persons Living in the Household and AgesFull Name (Age)List Current Psychological ConditionsCurrent MedicationsDo you attend church? Yes No Please SpecifyName of Church and Phone NumberBriefly state why are you seeking treatment:*General Health And Mental Health InformationHow would you rate your current sleeping habits?* Poor Unsatisfactory Satisfactory Good Very Good Please list any specific problems you are currently experiencing:How would you rate your current physical health?* Poor Unsatisfactory Satisfactory Good Very Good Please list any sleep problems you are currently experiencing:How many times per week do you generally exercise?What types of exercise do you participate in?Please list any difficulties you experience with your appetite or eating patterns:Are you currently experiencing overwhelming sadness, grief, or depression?* Yes No If yes, approximately how long?Are you currently experiencing anxiety, panic attacks, or have any phobias?* Yes No If yes, when did you begin to experience this?Substance AbuseDo you drink alcohol more than once a week? Yes No If yes, how often?Is alcohol an area of concern for you? Yes No If yes, explain:How often do you engage in recreational drug use? Daily Weekly Monthly Never Is recreational drug use an area of concern for you? Yes No If yes, explain: Family Mental Health History In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle ECT.). Alcohol/Substance Abuse Yes No Anxiety Yes No Depression Yes No Domestic Violence Yes No Eating Disorders Yes No Obesity Yes No Obsessive Compulsive Behavior Yes No Schizophrenia Yes No Suicide Attempts Yes No Suicide Attempts Yes No Abuse HistoryHave you experienced physical, sexual or emotional abuse? Yes No If yes, explainAdditional InformationWhat would you like to accomplish therapy?Briefly state why you are seeking treatment?Is there anything you feel we should know, or that you are concerned about? Insurance Information Information about Parent or Responsible Party for Insurance Is this a Self Pay? Yes No Full Name of Primary Insured* First Name Middle Initial Last Name Relationship to Patient*Birth Date* MM slash DD slash YYYY Social Security Number*Phone Number*Email address* Name of Employer and Phone Number*Insurance Carrier*Phone Number*Member ID*Plan or Group Number*Is this an Employee Assistance Program? Yes No Company Insurance Provider*Insurance Company Phone Number*Insurance Authorization Number*This field is hidden when viewing the formInsurance CardMax. file size: 50 MB.Please upload pictures of your insurance card FRONT and BackInsurance Card (not required if under EAP) Drop files here or Select files Max. file size: 50 MB. Please upload pictures of your insurance card FRONT and BackInsurance Card* Drop files here or Select files Max. file size: 50 MB. Please upload pictures of your insurance card FRONT and BackConfidentiality Agreement Tele Mental Health Informed Consent - Please click here to review this document Transcendent Truth Intake Assessment - Click here to review this document Informed Consent For Assessment and Treatment - Click here to review this document Notice of Privacy Practices - Click here to review this documentConsent* I have read the Tele Mental Health Informed Consent and agree to these conditions of treatment. By my signature below, I acknowledge my agreement to adhere to these conditions.*Consent* I have read the Transcendent Truth Intake Assessment of Privacy practices for Transcendent Truth Inc. By my signature below, I acknowledge I reviewed it.*Patient's Full Name* First Middle Last Today's Date* MM slash DD slash YYYY Δ
