Primary Telehealth Form

If this an emergency, please call 911

OR 988 - Suicide Crisis Lifeline.

Please complete the Primary 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: *

Primary Language *

Birthdate:*

Timezone:*

Gender:*

Male

Female

Transgender

Gender not listed

Age:

Email Address *

User Password *

Confirm Password *

Mobile Number *

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Contact Phone Number: *

Emergency Contact Email:

Emergency Contact Relationship:

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:

Number of People in your House :

Household Annual Income:

Relationship Status:

What type of Primary Healthcare Support are you looking for? (Check all that apply )

A. Sick Visit

B. Medication refill (non-narcotic)

Do you have the following?:

Medicaid

Medicare

Other

Work excuse/note:

Yes

No

School/ChildCare excuse/note:

Yes

No

Stomachache in left or right lower region or no bowel movement (poop) in more than 5 days ( GO TO THE EMERGENCY ROOM)
Chest pain and/or difficulty breathing ( GO TO THE EMERGENCY ROOM)
Pregnant (GO TO THE EMERGENCY ROOM)

Personal History

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

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

11. Legal Issues past, current, or pending?

Yes

No

12. Primary Care Physician?

Yes

No

Symptoms

Patient Health Questionnaire (PHQ 9)

Over the last 2 weeks, how often have you been bothered by the following problems?	Not at all	Several Days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things.	0	1	2	3
2. Feeling down, depressed, or hopeless.	0	1	2	3
3. Trouble falling asleep or sleeping too much.	0	1	2	3
4. Feeling tired or having little energy.	0	1	2	3
5. Poor appetite or overeating.	0	1	2	3
6. Feeling bad about yourself- or that you are a failure or have let yourself or family down.	0	1	2	3
7. Trouble concentrating on things, such as reading the newspaper or watching television.	0	1	2	3
8.Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual.	0	1	2	3
9. Thoughts that you would be better off dead, or of hurting yourself in some way.	0	1	2	3
TOTAL SCORE (add the marked numbers):	Total:

Family History

1. Check the conditions that apply to you or any of your immediate relatives: .

Asthma

Cancer

Cardiac disease

Diabetes

Hypertension

Psychiatric disorder

Epilepsy

Other

N/A

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

Yes

No

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

6. What is your current living situation?

Houseless

Self

With a Significant Other

With a Friend or Family Member

With Children

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 Primary Telehealth Provider to know?

Completing this section below helps us to determine the Primary Telehealth care provider that meets your needs:

Schedule (Check all that apply)

8am - 5pm

3pm - 11pm

11pm - 7am

Language

To/From (Primary Doctor or Physician):*

Phone:*

Your relationship to Client:*

Self

Parent/legal guardian

Personal representative

Other

Were you referred by a Digital Navigator?

Yes

No

Sign Here

Sign above

Date: