Adult Telehealth Intake Form Home » Adult Telehealth Intake Form Provider: Michael Fish, Ph.D. Adult Telehealth Intake Form "*" indicates required fields EmailThis field is for validation purposes and should be left unchanged.I. Patient InformationFull Name*Date of Birth MM slash DD slash YYYY Address Street Address City State ZIP Phone Number*Email* II. Emergency Contact InformationEmergency Contact NameRelationshipPhone NumberIII. Presenting ConcernsReason for Seeking TherapyIV. Medical & Mental Health HistoryPast Mental Health TreatmentMedical ConditionsHospitalizationsV. Current MedicationsList Current MedicationsVI. Substance UseAlcohol use (Amount and Frequency)Drug Use (Types and Dates)Tobacco UseVII. Family & Social HistoryMarital/relationship StatusChildren (Names, Ages)Support SystemVIII. Telehealth Consent Acknowledgment* VIII. Telehealth Consent Acknowledgment*I understand that telehealth involves the use of electronic communications to enable healthcare services at a distance. I consent to participate in telehealth psychotherapy sessions with Michael Fish, Ph.D.Signature*Date* MM slash DD slash YYYY
