New Patient Intake Form
Print this form, fill it in by hand, and bring it to your first visit.
Jayakumar Patil, MD
Bedford Psychiatric Care
80 Palomino Lane, Suite 203 · Bedford, NH 03110
(603) 669-7999
Mon - Fri · 10 AM - 5:30 PM
NEW PATIENT INTAKE FORM
Today's date
Appointment date
Referred by
1 — Personal information
Last name
First name
Date of birth (MM/DD/YYYY)
Age
Address
City
State / ZIP
Phone (best for callbacks)
Email address
Preferred contact method
Pronouns
2 — Emergency contact
Name
Relationship
Phone number
3 — Insurance
Insurance company
Member ID
Group number
Policy holder name (if not yourself)
Are you the primary policy holder?
4 — Reason for this visit
Briefly describe what is bringing you in. When did these concerns begin?
When did these symptoms begin?
Are symptoms getting worse / better / same?
Jayakumar Patil, MD · Bedford Psychiatric Care · Page 2
5 — Psychiatric history
Have you seen a psychiatrist before?
Have you been hospitalized for mental health?
Prior diagnoses (if any)
Prior psychiatric medications (name, dose, did it help, why stopped):
6 — Medical history
Known medical conditions:
Current medications (name, dose, frequency):
Supplements / vitamins / OTC medications:
Allergies (medication or other)
Primary care provider name and phone
7 — Family psychiatric history
Check any conditions present in immediate family members (parents, siblings, children):
Additional notes on family history:
8 — Social history
Occupation / school year
Current relationship status
Living situation
Alcohol use (drinks per week):
Cannabis / other substance use:
9 — Safety screening
These questions are a standard part of every psychiatric intake. Please answer honestly.
Do you currently have thoughts of suicide or self-harm?
Have you had thoughts of suicide or self-harm in the past year?
Have you ever attempted suicide?
Do you have thoughts of harming others?
10 — Signature
I certify that the information provided above is accurate and complete to the best of my knowledge.
Signature
Printed name
Date
If patient is a minor, parent / guardian signature:
Guardian signature
Printed name
Relationship to patient
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