MEDICAL RELEASE — Jersey Forensic Consulting

Jersey Forensic Consulting LLC VIVIAN CHERN SHNAIDMAN, M.D. Diplomate, American Board of Psychiatry and Neurology and Forensic Psychiatry 475 Wall Street, Princeton, NJ 08540

Name

First Name

Last Name

Today’s Date:

YYYY

SSN#:

Age:

Legal Gender:

Date of Birth:

YYYY

Marital status

Occupation

Employer

Current Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email:

Receive appointment reminders via email?

Yes

Receive details regarding treatments via email?

Yes

Mobile Phone:

Country

(###)

###

####

May we leave detailed messages on this phone?

Yes

Home Phone:

Country

(###)

###

####

May we leave detailed messages on this phone?

Yes

Alternative Phone:

(###)

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May we leave detailed messages on this phone?

Yes

PRIMARY INSURANCE COMPANY NAME:

PLEASE WRITE THE NAME OF YOUR INSURANCE COMPANY HERE! (EX AETNA, BC/BS ETC.) WE DO NOT ACCEPT ALL INSURANCES!!!

PATIENT ID#:

GROUP #:

Subscriber’s Name:

Subscriber’s DOB:

YYYY

Relationship to Insured Patient:

Subscriber’s Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

INSURANCE CO. PHONE:

(###)

###

####

INSURANCE CO. ADDRESS:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

SECONDARY INSURANCE COMPANY: NAME

PATIENT ID#:

GROUP #:

Subscriber’s Name:

First Name

Last Name

Subscriber’s DOB:

YYYY

Relationship to Insured Patient:

Subscriber’s Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

INSURANCE CO. PHONE:

Country

(###)

###

####

INSURANCE CO. ADDRESS:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

RESPONSIBLE PERSON: (Is this information same as the patient?)

If yes, you may skip this section

Yes

Name

First Name

Last Name

Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Relationship to Patient:

Emergency Contact

Name

First Name

Last Name

Phone

(###)

###

####

Relationship to Patient:

PRIMARY CARE PHYSICIAN:

PHONE

Country

(###)

###

####

REFERRING PROVIDER: (If none, how did you hear about us?)

A friend

Facebook

Psychology Today

Internet

Other (provide details)

THERAPIST:

Phone:

Country

(###)

###

####

Date of last visit:

YYYY

WHY ARE YOU SEEKING TREATMENT NOW? Describe

MEDICAL HISTORY:

List any medical problems:

List any hospitalizations (Including Psychiatric or Substance Abuse):

Please list all medications (prescribed or over the counter):

Name of Medicine

Dose

Reason prescribed

Prescribed by

Date started

Food or Drug Allergies:

PSYCHIATRIC HISTORY: Please circle either “No” or “Yes” to the following questions.

Have you ever been given a psychiatric diagnosis?

Yes