+1 469-397-4234
1400 Coit Rd Bld 22
08:00 am - 05:00 pm
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PTSD
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Valant Adult Intake form
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Frisco Office
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1
Step 1
First Name
Last Name
Email
email
Phone Number
What is the main reason for the visit?
Are you currently under the care of a Psychiatrist?
Have you ever been diagnosed with any Psychiatric Condition?
Are you currently taking any medication?
If yes, what is the name of the medication?
Do you have any insurance?
If yes name the carrier?
Do you have any history of the following condition?
Seizure Disorder
Yes
No
Wolff Parkinson White Syndrome
Yes
No
Stroke
Yes
No
Fibromyaigia
Yes
No
High Blood Pressure
Yes
No
Chronic Pain Issue
Yes
No
Heart Diseases Such As Arrhythmia
Yes
No
Neurological Disorders
Yes
No
Has there been a history of the following?
Do you have any current/past history of drug abuse?
If yes when?
Do you have any current/past history of alcohol abuse?
If yes when?
Do you have any current/past history of marijuana abuse?
If yes, when was the last time you used?
Do you have any pending legal issues?
If yes please explain
Will you be requiring a disability document to be filed?
Please answer, if the appointment is for a child
Yes
No
Are the parents of the child divorced?
Are there any custody issues?
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