The Counseling Center 
                                                       One Main Street * Nashua, NH 03064   (603) 883-0005                                    
                                                       148 Coolidge Avenue * Manchester, NH  03102 * (603) 627-3111
                                                       294 D.W. Highway * Merrimack, NH  03054 * (603) 883-0005
                                                       50 Nashua Road * Suite 305 * Londonderry, NH  03053 * (603) 432-3033
                                                      208 Robinson Road * Suite 204 * Hudson, NH  03051 * (603) 598-9958
                                                      45 Main Street * Peterborough, NH  03458 * (603) 924-3331
                                                      
414 State Street * Unit 2 * Portsmouth, NH  03801 * (603) 334-2533
                                                      24 Front Street * Suite 304 * Exeter, NH 03833 * (603) 778-2005  
                                                      16 Lincoln Street * Suite C * Brunswick, ME 04011 * (207) 406-4222
                                                      319 Whittier Highway * Suite 8 * Center Harbor, NH 03326 * (603) 546-6178 
                                                                                          Fax all locations: 603-883-0007

Clinical Information and History To Be Reviewed Confidentially by Your Doctor

PRIVACY NOTE:  This form meets HIPAA guidelines for privacy and secure electronic transmission.  Please note the lock on the bottom right corner of your web browser ensures your privacy, and all information is encrypted during transmission once completed.  Only administrative staff trained in HIPAA privacy rules and confidentiality will handle the print out of this document for delivery to your medical record prior and your provider.  Completion of this form will substantially expedite the information gathering process for your first appointment, and allow your provider to focus more specifically on the issues that require attention by avoiding additional spent on general background and medical information. Your cooperation is appreciated.

~~ Please Note:  Only complete this form if you have spoken to our Intake Department and have already scheduled your first appointment. If you have not, please complete the Request Appointment Form for an Adult or Child/Teen ~~

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What problems are leading you to seek help now?

Current Symptoms

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History of Presenting Problem


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PSYCHIATRIC HISTORY


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Please indicate if you currently consume or did consume in the past any of the substances listed below: *
 
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Substance Use Treatment History

Social History


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Do you

 

MEDICAL HISTORY







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OB/GYN HISTORY (IF APPLICABLE):
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Are you pregnant currently or trying to become pregnant?
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Please indicate if you have had any of the following tests completed in the past:

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Please complete only if your appointment is for an Psychiatrist (M.D) or Advanced Registered Nurse Practitioner (ARNP). If your appointment is with a psychologist or counselor, please omit.

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~~ Please Note:  Only complete this form if you have spoken to our Intake Department and have already scheduled your first appointment. If you have not, please complete the Request Appointment Form for an Adult or Child/Teen ~~