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

*Insured’s Name: *DOB: *Sex: M F

*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: 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_____________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________