OPA New Client Form Name * First Name Last Name Birthdate * MM DD YYYY Gender * Male Female Non-Binary Transgender Gender Neutral Other Prefer Not To Disclose Phone Number * (###) ### #### What is your preferred form of contact for appointment related information? * Phone Email Text Okay To Leave A Voicemail? * Yes No Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Address If Different From Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country How did you hear about me? Emergency Contact * Name, Phone Number, & Relationship To You Insurance If you would like to utilize your health insurance benefits, please complete this section. If not, please skip to the "Client Background Information" section of this form. I would like Olympia Psychology Associates to submit insurance claims on my behalf. Yes No Primary Insured's Name If different from your own. Primary Insured's Birthdate If different from your own. Carrier's Name Policy or Member # Group Number Type of Plan i.e. PPO, HMO, etc. Employer Through Which The Plan Is Issued Co-Payment Amount, AS Verified By Your Insurance Company As verified from your insurance company Do You Have A Yearly Deductible That Applies To Outpatient Mental Health And, If So, How Much Remains? Secondary Insured's Name If Applicable Secondary Insured's Birthdate Carrier's Name Policy or Member # Group Number Type of Plan Employer Through Which The Plan Is Issued Co-Payment Amount, AS Verified By Your Insurance Company Do You Have A Yearly Deductible That Applies To Outpatient Mental Health And, If So, How Much Remains? Client Background Information What brings you into therapy now? * What strengths do you possess that may help you achieve your treatment goals? What barriers get in the way of you achieving your treatment goals? Client Occupation Relationship Status Single Married Partner Divorced Spouse or Partner's Occupation Who lives in your home with you? Have You Been In Therapy Before? * Yes No If yes, when, for how long, and with whom? Are You Currently Taking Any Medications For A Psychiatric Diagnosis? * Yes No If yes, please list your medications and the name of the prescribing physician: Is There A History Of Mental Health Problems In your Immediate Or Extended Family? * Yes No I Don't Know If yes, whom, and what diagnosis? Do You Or Anyone In Your Immediate Or Extended Family Have A Problem With Addictive Behavior? * i.e. drugs, alcohol, gambling, shopping, sex, etc. Yes No I Don't Know If yes, whom? Have you ever experienced physical, emotional or sexual abuse? * Yes No If yes, please comment on what you feel might be helpful for me to know: Have you ever thought about or attempted suicide or other forms of self-harm (for example, cutting)? * Yes No If yes, please describe: i.e. when, how, number of attempts, etc. Have you ever been hospitalized for mental health issues? Yes No If yes, please describe: Is there a history of suicidal or self-harm behavior in your family? * Yes No I Don't Know If yes, please describe: Please comment on anything else you think I need to know: Thank you!
