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Laurie Friedman Donze, Ph.D., P.C.

784-B Shelton Road
Crownsville, MD 21032
443-286-1787

PRIMARY CLIENT INFORMATION

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PARTNER INFO

Second client Registration

PRIMARY INSURED

Insurance Self Pay EAP Third Party

May we call at work?

Yes

Primary Insurance Information

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SECONDARY INSURED ("If Applicable")

May we call at work?

Yes

Secondary Insurance Information

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Terms And Conditions

Please complete and sign the following documents before your first appointment or as requested by Dr. Donze throughout treatment. Thank you.

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%3cdiv contenteditable%3d%27false%27 unselectable%3d%27on%27 class%3d%27unselectable%27%3e%3cp%3e%3cspan style%3d%22color%3a rgb%2836%2c 52%2c 61%29%3b font-family%3a %26quot%3bMS Sans Serif%26quot%3b%3b font-size%3a 14px%3b text-align%3a justify%3b%22%3ePlease go to %3ca href%3d%22https%3a//www.doctordonze.com/index.php/forms%22 target%3d%22_blank%22%3ehttps%3a//www.doctordonze.com/index.php/forms%3c/a%3e%26nbsp%3band print the forms indicated.%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22color%3a rgb%2836%2c 52%2c 61%29%3b font-family%3a %26quot%3bMS Sans Serif%26quot%3b%3b font-size%3a 14px%3b text-align%3a justify%3b%22%3ePlease print and complete the forms and bring them to your first appointment. If you take any psychiatric medications%2c please complete the medication log and sign the authorization to release records for your psychiatrist or prescribing physician. If you have any questions or concerns about any of these forms%2c please bring them up our first meeting. Thank you.%3c/span%3e%3c/p%3e%3c/div%3e

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Laurie Friedman Donze, Ph.D., P.C.

784-B Shelton Road
Crownsville, MD 21032
443-286-1787

Intake

1. How did you hear about us?

2. What type of therapy are you seeking? Individual Couples Family Hybrid

3. What brings you in?

4. What would your partner say?

5. Length of these relationship:

6. Can you tell me a little bit about yourself and your family/culture/upbringing?

7. Can you tell me a little bit about what intimate relationships look like for you?

8. Do you have any dependents?

9. Therapy before:

10. Psychiatry before:

11. Medications (type & dosage frequency):

12. Alcohol and Drug Use (type & dosage frequency):

Describe use:

13. Marijuana/Cannabis products: Yes No

Do you have a medical marijuana card? Yes No

Describe use:

14. Recreational drugs: Yes No

Describe use:

15. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

16. Self Harming Behaviours: Yes No

Describe, including most recent incident:

17. Violence Towards Others: Yes No

Describe, including most recent incident:

18. Physical/Emotional/Sexual abuse in the past: Yes No

Describe:

19. Experience of life being threatened by person, accident, or natural disaster: Yes No

20. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

21. Actions taken concerning above risks:

22. Religious Affiliation/Denomination:

23. Occupation:

24. Preferred Location:

25. School: (grade/year, graduation date & current GPA):

26. City Year Employee: (site name, site grade level, & program manager):

27. Availability:

28. Clinician assigned:

29. Initial Appointment:

30. Client Informed of Fee: Insurance and/or Sliding scale amount:

31. Client Informed of 2 business day cancellation policy: Yes No

32. Who did the intake:

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Laurie Friedman Donze, Ph.D., P.C.

784-B Shelton Road
Crownsville, MD 21032
443-286-1787

Intake

1. Occupation:

Youth worker:

No describe

Yes describe

2. If City Year Employee: (site name, site grade level, & program manager):

3. How did you hear about us?

4. What type of therapy are you seeking? Individual Couples Family Hybrid Group

5. What brings you in?

6. Client stated strengths

7. Can you tell me a little bit about yourself and your family/culture/upbringing?

8. Tell me a little bit about your community & social supports

9. Do you have any dependents?

10. Therapy before:

11. Psychiatry before:

12. Medications (type & dosage frequency):

13. Alcohol and Drug Use (type & dosage frequency):

Describe use:

14. Marijuana/Cannabis products: Yes No

Do you have a medical marijuana card? Yes No

Describe use:

15. Recreational drugs: Yes No

Describe use:

16. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

Access to any weapons, if so type:

17. Self Harming Behaviours: Yes No

Describe, including most recent incident:

18. Violence Towards Others: Yes No

Describe, including most recent incident:

19. Physical/Emotional/Sexual abuse in the past: Yes No

Describe:

20. Experience of life being threatened by: Person Accident Natural Disaster

21. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

22. Actions taken concerning above risks:

23. Religious Affiliation/Denomination:

24. Preferred Location:

25. School: (grade/year, graduation date & current GPA):

26. Availability:

27.Insurance and/or Sliding scale amount:

Everything below is for Office Staff Only to Complete

28. Clinician assigned:

29. Initial Appointment:

30. Client Informed of Fee:

31. Client Informed of 2 business day cancellation policy: Yes No

32. Who did the intake:

32. Youth worker: Yes No

33. Describe if not occupation (under occupation)

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Laurie Friedman Donze, Ph.D., P.C.

784-B Shelton Road
Crownsville, MD 21032
443-286-1787

Intake

1. How did you hear about us?

2. What type of therapy are you seeking? Individual Couples Family Hybrid

3. What brings you in?

4. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

5. Violence Towards Others: Yes No

Describe, including most recent incident:

6. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

7. Client Informed of Fee: Insurance and/or Sliding scale amount:

8.Client Notes

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Laurie Friedman Donze, Ph.D., P.C.

784-B Shelton Road
Crownsville, MD 21032
443-286-1787

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Driver License Front
                                                                    

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Driver License Back
                                                                    

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Laurie Friedman Donze, Ph.D., P.C.

784-B Shelton Road
Crownsville, MD 21032
443-286-1787

Intake

Intake Question

Referral Source

Are you currently on active duty? Yes No

Military Branch

Highest Level of Education

Employment status

Are you currently enrolled in school or job training program?

Are you currently using? Yes No

Routine of administration types:

During the past 30 days, how many days have you used any of the following:

Cocaine/crack

Marijuana/Hashish

Heroine

Morphine

Dilaudid

Demerol

Fentanyl

Percocet

Darvon

Codeine

Tylenol 2, 3, 4

OxyContin/Oxycodone

Non-prescription methadone

Hallucinogens/psychedelics, PCP, LSD, Mushrooms, or Mescaline

Methamphetamine or other amphetamines

During the past 30 days, how many days have you used any of the following:

Benzodiazepines: diazepam, alprazolam, Triazolam, and etizolam

Barbiturates: Metharbital and pentobarbital sodium

Non-prescription GHB

Ketamine

Other tranquilizers, downers sedatives, or hypnotic

Inhalants

Other illegal drugs

Drug of Choice-Diagnosis

Behavioral Health

Children's Services Referral Yes No

If Children's Services referral, do you have an active Children's Services case? Yes No

# of children that you have

Crime Justus status

Probation Yes No

Parole Yes No

PROB 45 Yes No

Human Trafficking

Is there a history of Sexual Abuse?

Program Placement (Level of Care)

Sober Housing Needed Yes No

Sober Housing Provided Yes No

Medical Intake Questions

If female, are you pregnant? Yes No

Medicated Assisted Treatment (MAT)

Hypertension

Diabetes

STI's

UTI's

Cellulitis

COPD

Asthma

Blood dyscrasia

City

State

Zip code

County

Is there a history of drug use? Yes No

In the past 30 days, where have you been living most of the time?

Are you currently employed?

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Notes

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Card Holder Name:

Card Type:

Card Number:

Expiration Date:

Address:

Zip:

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Electronic Signature

Laurie Friedman Donze, Ph.D., P.C.

784-B Shelton RoadCrownsville, MD 21032443-286-1787

PRIMARY CLIENT INFORMATION

PARTNER INFO

PRIMARY INSURED

Primary Insurance Information

SECONDARY INSURED ("If Applicable")

Laurie Friedman Donze, Ph.D., P.C.

784-B Shelton RoadCrownsville, MD 21032443-286-1787

Laurie Friedman Donze, Ph.D., P.C.

784-B Shelton RoadCrownsville, MD 21032443-286-1787

Laurie Friedman Donze, Ph.D., P.C.

784-B Shelton RoadCrownsville, MD 21032443-286-1787

Laurie Friedman Donze, Ph.D., P.C.

784-B Shelton RoadCrownsville, MD 21032443-286-1787

Laurie Friedman Donze, Ph.D., P.C.

784-B Shelton RoadCrownsville, MD 21032443-286-1787

784-B Shelton Road
Crownsville, MD 21032
443-286-1787

784-B Shelton Road
Crownsville, MD 21032
443-286-1787

784-B Shelton Road
Crownsville, MD 21032
443-286-1787

784-B Shelton Road
Crownsville, MD 21032
443-286-1787

784-B Shelton Road
Crownsville, MD 21032
443-286-1787

784-B Shelton Road
Crownsville, MD 21032
443-286-1787