Patient Intake Questionnaire

Personal information

Last name *

First name *

Date of birth

Age

Street address

City

State / ZIP

Phone (best for callbacks) *

Email address

Preferred contact method

Phone callText messageEmail

Pronouns

He / himShe / herThey / themOther

How did you hear about us?

Emergency contact

Name

Relationship

Phone number

Insurance

Insurance company

Member ID

Group number

Policy holder name (if not yourself)

Are you the primary policy holder?

YesNo

Family psychiatric history

Check any conditions present in immediate family members (parents, siblings, children).

Family members on psychiatric medication — which ones worked

Safety screening

These questions are a standard part of every psychiatric intake. Please answer honestly — your responses help Dr. Patil build the safest plan for you.

If yes to any of the above, please briefly describe

Signature

I certify that the information provided above is accurate and complete to the best of my knowledge.

Signature (type your full name) *

Date

If patient is a minor — parent / guardian

Guardian signature (type full name)

Relationship to patient

Your information stays on your device. This form does not submit or store any data. Click Download PDF to save a copy — bring it to your first visit or email it to the office at drjpatil56@gmail.com.

Personal information

Emergency contact

Insurance

Reason for this visit

Psychiatric history

Medical history

Family psychiatric history

Social history

Safety screening

Signature