Yogameta

Roselle, New Jersey USA

(908) 987-3332

Appointments Available After Consultation

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Tiffany Lewis

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Please fill out the intake form at your earliest convenience. Someone from our team will get in touch with you within 48 hours.

Thank you!

Divine Transition Counseling Services Intake Form

First Name *

Last Name

Address *

City *

State *

Postal code *

Date of birth *

Email *

Phone *

Preferred Method of Contact *

Phone

Email

Social Security Number *

Marital Status *

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Single
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Employment *

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Primary Care Provider *

Referral Name

Emergency Contact Information

Name *

Street Address *

Emergency Contacts City *

Emergency Contact State *

Zip/Postal Code *

Emergency Contact's Phone Number *

Relationship *

Insurance Information

Name of Insurer *

Insurer Phone Number *

Subscriber Name *

Subscriber Date of Birth *

Subscriber Relationship to Patient *

Policy Number *

Group Number *

Medical History

Please check all that apply *

None

Anemia

Anxiety

Asthma

Benign Prostatic

Blood Clots

Cerebrovascular Accident

COPD (Emphysema)

Depression

Gallbladder Disease

Hepatitis C

Hypertension

Liver Disease

Myocardial Infarction

Osteoporosis

Renal Disease

Thyroid Disease

Allergies

Angina

Arthritis

Atrial Fibrillation

Hypertrophy

Cancer

Cronary Artery Disease

Crohn's Disease

Diabetes

GERD (Reflux)

Hyperlipidemia

Irritable Bowel Disease

Migraine Headaches

Osteoarthritis

Osteoarthritis

Peptic Ulcer Disease

Seizure Disorder

Do you use tobacco? *

No

Daily

Weekly

Less

Former User

Do you use alcohol? *

No

Daily

Weekly

Less

Former User

Caffeine use? *

No

Daily

Weekly

Less

Former User

Have you been convicted of drug related charges? *

Yes

No

Are you currently taking prescription medication? *

Yes

No

Have you had any surgeries in the past 5 years? *

Yes

No

Family History *

Adopted

Allergies

ArthritisBlood Disease

Cancer

Depression

Diabetes

Hearing Deficiency

Hypertension (High Blood Pressure)

Learning Disability

Tuberculosis

Osteoarthritis

PVD

Alcoholism

Asthma

CAD (Heart Attack)

CVA (Stroke)

Developmental Delay

Eczema

Hyperlipidemia (High Cholesterol)

Irritable Bowel Disease

Mental Illness

Obesity

Osteoporosis

Renal Disease

Other - Family History

Mental Health History

Why you are seeking treatment? *

What do you expect from this counselling? *

Have you seen a counselor, psychologist, psychiatrist or other mental health professional before? *

Yes

No

Average hours of sleep per night *

Please describe any other experiences you have had problems with *

Additional comments or concerns *

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Roselle, New Jersey USA

(908) 987-3332

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