New Client Packet Checklist: Welcome to Life in Balance Center. Full completion of this packet will enable us to provide you with the best possible service. This packet about 45 to 60 minutes to complete. To enable us to provide you with the best care possible, please be sure to fill out all pages front and back. Please bring the following to your first appointment. They are required for insurance and medical records compliance: Insurance card Driver’s license or Photo ID Any additional medical records or you may have from previous practitioners Copay or other payment required by your insurance company Please note the following: Client registration (next page) must be filled out completely. The date of and social security number of the insurance policy holder is required to submit insurance claims. If you do not have this information, we cannot bill your insurance. You would then be held responsible for charges that your insurance would otherwise cover. Please fill this packet out as completely as you can. This will help your practitioner understand more about your visit. The Authorization to Release Protected Information is the last page of the packet. Please fill in your name and date of birth, the name of the practitioner that you will be working with at Life in Balance on the line next to clinician’s name, and the name and demographic information of the person or entity that you wish to share your information with. Please wait to sign and date this sheet until you check in with our receptionist so that they can witness your signature. Please review and check that each page has been signed and initialed. Thank you for your cooperation and patience in filling out these forms to help us better understand your needs and bill your insurance correctly. We appreciate the opportunity to serve you. CLIENT REGISTRATION
SYMPTOMS: Please any problems that either you have had in the past or are currently having. Now Past Change in appetite (more or less) Feeling sad Crying spells Too little sleep (falling or staying asleep) Sleep more than usual Fatigue Loss of interest &/or pleasure Avoiding friends or family Expect failure Decreased concentration Thoughts of death Cutting or burning oneself Suicide plan or attempt Depression Often sick Loneliness Slow moving Hopelessness Confusion Worthlessness Friendly Lack of confidence/Low self-esteem Guilt Reckless or dangerous behavior Racing thoughts Pressured speech Inflated self-esteem Obsessive thoughts Compulsive or repetitive behavior Marital/family problems Sexual problems Relationship problems Long term memory problems Short term memory problems Wound up or tense more days than not attacks Irritable Anxiety Easy Muscle tension Irrational fear of something or someone Talking/acting w/out thinking Fidgety, restless, overactive Difficulty paying attention Frequent day dreams Bored easily Learning difficulties lose things Excessive dieting/exercise Obsessed with losing weight Use of laxatives Engage in self-induced vomiting Eating things that are not food Vandalism Fire-setting Lack of remorse for wrong-doing Selfish Bullies/gets in fights Lying Truancy Theft Argumentative/sudden anger Defiant of authority Temper tantrums Stubborn adults Afraid to leave a loved one Easily embarrassed Upset by minor changes Feeling detached from one’s body Feelings of unreality See or hear things others don’t Believe things others tell you aren’t true Fear of strangers Difficulty trusting Believe others are out to get you Intrusive thoughts Avoid things related to traumatic event Startle easily Flashbacks Nightmares symptoms not mentioned above How do your symptoms affect your life?