Mental Telehealth Form

If this an emergency, please call 911

OR 988 - Suicide Crisis Lifeline.

Please complete the Mental Telehealth Registration Form
for the person in your household who needs the service.

There is No Cost for our Essential Telehealth services. Essential Families receives grants and donations to cover the cost. Medication payment is not included.

Registration/Effective Date : *

Termination Date : *

First Name: *

Last Name: *

Address:*

City:*

State:*

Zip Code: *

Language:

Birthdate:*

Timezone: *

Gender:*

Male

Female

Transgender

Gender not listed

Age:

Email Address *

User Password *

Confirm Password *

Phone Number *

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Contact Phone Number:*

Emergency Contact Email:

Emergency Contact Relationship:

Emergency Contact Relationship - Other

Do you have children living in your home?*

Yes

No

How many children?*

Ages of children living in your home * (Select all that apply)

Race Ethnicity:

Race Ethnicity - Other

Number of People in your House :

Household Annual Income:

Relationship Status:

What type of Mental Healthcare Support are you looking for?

A. Counseling

Counseling - Other

B. Therapy

Counseling - Other

C. Check all that apply:

Peer coaching

Anxiety

Depression

Post-Partum

Other

Other

D. Do you have the following:

Medicaid

Medicare

Other

Other

E. Medication refill (non-narcotic)

Name of medication

Personal History

1. What do you think you need the most help with right now? Please identify your main concerns below:

Social Interactions:

Friends

Peers

Coworkers

Family

Education:

Learning difficulties

Motivation

Grades

Behavioral Issues

NA

Interpersonal Issues:

Healthy relationships

Boundary setting

Sexual issues

Abuse

Concerns

NA

2. In your own words, what brings you to counseling at this time? Be as detailed as you can.

3. If attending, what is school like for you?

4. If attending, what school do you go to?

5. Have you ever been suspended or expelled from school?

Yes

No

6. What is your highest level of education

7. What is your current occupation?

Student

Unemployed

Disabled

Employed

Employer

Month

Year

8. What do you like to do for fun?

9. Do you currently drink alcohol?

Yes

No

10. Do you smoke cigarettes or use drugs?

Cigarettes

Drugs

Both

NA

How often?

11. Legal Issues past, current, or pending?

Yes

No

Please Describe

12. Primary Care Physician?

Yes

No

Name

Address

Phone Number

Symptoms

1. Please check any symptoms that you have or are experiencing.

Alcohol Craving

Anxiety

Appetite Changes

Attempted Suicide

Avoiding Place/Situations Due to Fear/Panic

Concentration Problems

Confusion

Constant Suspicion or Distrust

Crying Frequently

Decreased Appetite

Other

N/A

Other

2. Please check any of the following you have experienced within the last 6 months.

Anxiety

Decreased appetite

Depressed Mood

Difficulty Sleeping

Head Injury

Excessive Sleep

Fatigue/Low Energy

Fear

Other

N/A

Other

3. Please check any of the following that apply.

Angina or Chest Pain

Arthritis

Asthma

Bone or Joint Problems

Chronic Fatigue

Chronic Pain

Diabetes

Dizziness

Faintness

Fibromyalgia

Other

N/A

Other

Psychiatric History

1. Have you seen a mental health professional before?

Yes

No

Reason for counseling?

Diagnosis

Date?

Describe your counseling experience.

2. Do you have or have you ever had suicidal thoughts?

Yes

No

Date?

If you are currently experiencing suicidal thoughts or ideations please call 988 for immediate assistance.

3. Have you ever attempted suicide?

Yes

No, I have never attempted suicide.

Check all that applies:

Firearm

Suffocation

Poisoning

Other

4. Do you have thoughts or urges to harm others?.

Yes

No

When?

5. Have you ever harmed others?

Yes

No

When?

What happened?

6. Have you ever been hospitalized for a psychiatric issue?

Yes

No

When?

Why?

Length of stay

Family History

1. Have any family members struggled with the following challenges? Please specify which family member.

Alcoholism/Drug addiction

Anxiety/ Panic Attacks

Depression/ Bipolar Disorder

Eating Disorders (Anorexia/Bulimia)

Hyperactivity/ADHD

Learning Challenges/Disability

Suicide Attempts

Trauma (Sexual Assault, Combat, Abuse, etc.)

Other

N/A

Other

2. Has anyone been diagnosed with anything in your family?

Yes

No

Who?

Diagnosis.

3. Please describe your relationship with your biological mother.

4. Please describe your relationship with your biological father.

5. Do you have siblings?

Yes

No

Please describe your relationship with them

6. What is your current living situation?

Houseless

Self

With a Significant Other

With a Friend or Family Member

With Children

Who all lives with you (names and ages)?

7. Who would you consider as your closest source of support?

Parent

Grandparent

Aunt

Uncle

Sibling

Friend

Cousin

Teacher

Spouse

Significant Other

Other

8. If you are in a relationship, please describe the nature of the relationship and length of time together.

9. What else would you like your Mental Telehealth Provider to know?

Completing this section below helps us to determine the Mental Healthcare provider that meets your needs:

Schedule (Check all that apply)

8am - 5pm

3pm - 11pm

11pm - 7am

Language

Date:

69895 Individuals/Families Helped

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