Date* Date Format: MM slash DD slash YYYY Name* First Last Age*SSN (Last 4 Numbers)*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Alternate PhoneAre you employed?*YesNoEmergency Contact Name*Relationship*Emergency Contact Phone*Please READ **If you are having thoughts of harming yourself or others, STOP HERE and call 911 or the GA Crisis Line 1-800-715-4225**Are you currently a client at this Center or any View Point Health Center?*YesNoDo you have insurance?*YesNoIf yes, what is name of insurance?Current clients: Are you having problems with your medication?*YesNoCurrent clients: Do you need a refill on your medication?*YesNoNEW Clients: How did you hear about us?*FriendHospitalGCALProbation/ParoleParent Accountability CourtWebsiteIf referred by GCAL, when was the referral made? Date Format: MM slash DD slash YYYY Tell us why you are here today (check all that apply)* To begin outpatient mental health treatment To begin outpatient substance abuse treatment Recently released from jail/prison Open DFCS case To be assessed for crisis and/or inpatient treatment/hospitalization or detox For information only (stop here) Other If Other, please explain:If Hospital discharge (within last 2 weeks)Hospital NameHospital Admit Date Date Format: MM slash DD slash YYYY Hospital Discharge Date Date Format: MM slash DD slash YYYY What problem(s) have you experienced in the last 3 days (check all that apply):* Select All Depression Problems in relationships Work/School Stress Legal Issues/Court-Mandated Anger/Aggression Family recommended Treatment Domestic Violence Thoughts of Killing Myself Paranoia Change in Sleep Patterns Anxiety Detox/Alcohol and Drug Use Thoughts of Killing Others Seeing/Hearing Things Others Do NOT Hear/See Other If Other, Please Explain:Do you own a weapon, have access to, or are you currently carrying a weapon?*YesNoAre you seeking to have paperwork completed for work, SSI, FMLA, etc.?*YesNo***Please know that View Point Health no longer prescribes any Controlled Substances (ex: Xanax, Valium, Klonopin, Ativan or any ADHD medications for adults** ***SSI Disability Information Requests*** View Point Health will NOT complete SSI Questionnaires or similar forms about your treatment unless you (A) been in services with VPH for a minimum of (90) consecutive days and (B) been examined by a VPH medical doctor at least once during the 90 daysAgree* However, even if these conditions are met, View Point Health reserves the right NOT to fill out such documentation. Please Initial:Initial*
