Intake Form – Vivabest Psychiatry

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About Us
Our Team
Services
Conditions we Treat
Fees & Insurance
Resources
Refer to Us
FAQ
Contact Us

Vivabest Psychiatry-Intake Form

Please note that all items market with an asterisk(*) must be completed before you can submit the form.

www.vivabest.com Email: hello@vivabest.com Phone: 602-830-0399

Vivabest Psychaitry - Intake Form

"*" indicates required fields

First Name*

Middle Name

Last Name*

Date of Birth*

MM slash DD slash YYYY

Nickname

Email Address*

Phone Number*

Pronouns (Optional):

She/Her

He/Him

They/Them

Address*

State*

City*

Zip Code*

Please enter a number from 10000 to 99999.

Employment Status*

Full-time

Part-time

Looking for work

Disability

Retired

Student

How did you hear about us?*

Internet

Therapist

PCP/Family Doctor

Other

EMERGENCY CONTACT DETAILS

Emergency Contact Name

Relationship

Emergency Contact Phone

Emergency Contact Address

PRIMARY CARE PROVIDER (PCP)

Provider Name*

Contact Number*

Do you have a psychiatric provider*

Provider Name*

Contact Number*

PHARMACY

Pharmacy Name*

Phone*

Address*

MENTAL HEALTH INFORMATION

Primary Mental Health Concerns (in your own words)*

What brings you here today? (Select all that apply)*

Address specific symptoms (e.g., anxiety, depression)

Stress and cope with a recent life stressor

Psychiatric evaluation

Medication management

Other

Please elaborate on your reason for seeking care (Select all symptoms currently experienced)*

Depressed mood

Poor concentration

Avoidance

Loss of interest

Crying spells

Forgetfulness

Hallucinations

Excessive energy

Anxiety attacks

Excessive worry

Suspiciousness

Decrease need for sleep

Sleep disturbances

Excessive guilt

Impulsivity

Unable to enjoy activities

Racing thoughts

Decreased libido

Increased libido

Fatigue

Increased irritability

Change in appetite

Increase risky behavior

MEDICAL HISTORY

Do you have any of the following physical conditions?*

Asthma

High Blood Pressure

Heart disease

Seizures

Diabetes

Head injury

Kidney disease

Liver disease

N/A

Drug Allergies*

Reproductive Health

Are you pregnant or planning to become pregnant?*

Yes

No

N/A

Current Medications

Please list all medications you currently take (Psychiatric and Medical)*

RISK ASSESSMENT

In the past week, have you experienced thoughts of harming yourself?*

Yes

No

In the past week, have you experienced thoughts of harming others?*

Yes

No

Do you currently have access to means (e.g., weapons, medications) to harm yourself or others?*

Yes

No

Have you had any recent psychiatric hospitalizations or emergency mental health interventions?*

Yes

No

Are you currently experiencing any active substance use that interferes with your daily functioning?*

Yes

No

SERVICES REQUESTED & PREFERRED FORMAT

Other services you may be interested in*

Transcranial Magnetic Stimulation (TMS)

Spravato

ADHD Evaluation

N/A

Preferred Format*

Office

Virtual

PRIMARY HEALTH INSURANCE

Insurance Provider*

Policy Number*

Name of Insured Person*

Policy Holder DOB

MM slash DD slash YYYY

Relation to Patient*

Self

Spouse

Other

SECONDARY INSURANCE

Do you have secondary insurance?*

Yes

No

Please review our Terms of Service before signing.

By signing below I acknowledge that I have fully read, understood, and agree to the Terms of Service.

Patient Signature (PRINT NAMES)*

Date*

MM slash DD slash YYYY

CAPTCHA

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Arizona Office

Address: 5654 W Bell Rd. Suit C. Glendale AZ 85308

Phone: 602-830-0399

Fax: 602-830-0899

Email: hello@vivabest.com

Hours: Monday to Friday – 9am to 5pm Phoenix AZ (MST)

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Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition.