RECOVERY CENTER STUDENT APPLICATION
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- Edgar Hensley
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1 Boston University College of Health & Rehabilitation Sciences: Sargent College Center for Psychiatric Rehabilitation Stephanie Cummings, Administrative Manager Recovery Services Division 940 Commonwealth Avenue West Boston, Massachusetts T F RECOVERY CENTER STUDENT APPLICATION Instructions: Please complete all parts of your Student Application Packet, and fax it to Stephanie Cummings at (617) or by stephc13@bu.edu. After receiving your packet, she will contact before the start of the upcoming semester to arrange a tour and meeting here at the center. PART 1: CONTACT INFORMATION [Last Name] [First] [Middle Initial] [Street] [Apartment/Suite Number] [City/Town] [State] [Zip Code] Phone: [Home] [Cell] Birthday: Preferred Pronouns: [Month] [Day] [Year] [e.g. she/her/hers] *Recovery Center uses and text messaging to communicate with students. These are not secure modes of communication. By checking this box, you are agreeing to receiving s and text messages from the center. You are accepting and understanding the risk of having your association with the center, possibly compromised with the use of unsecure and text messages. Initials Date: 1
2 PART 2: DEMOGRAPHIC INFORMATION 1. What is your gender identity? Female Male Female to male transgender (FTM) Male to female transgender (MTF) 2. What is your race? Hispanic or Latino Black or African American White Native American or American Indian Agender Other (please specify): I don t know the answer Asian/Pacific Islander Other (please specify): I don t know the answer 3. What is the highest degree or level of school you have completed? Some High School /GED 4-Year College Degree (BA, BS) High School Diploma/GED Some Graduate Coursework Some Undergraduate Coursework Graduate Degree (e.g. MA, MFA, PhD, MD) 2-Year College Degree (Associates) 4. What is your current marital status? Single/Never Married Married Separated 5. What is your current employment/ volunteer status? Employed Full-time (40+ hours per week) Employed Part-time (1-39 hours per week) Unemployed 6. What is your current religious affiliation? Christianity Judaism Buddhism Islam Hinduism 7. Military Status: No, Military Service National Guard Divorced Widowed Volunteer Full- time (25+ hours a week) Volunteer Part- time (1-20 hours a week) Agnosticism Unaffiliated Other (please specify): I don t know the answer Armed Forces Other (please specify): 8. Citizenship Status U.S Citizen by Birth (Native) U.S Citizen Naturalized Non-resident Visa type Exp. Date: Permanent Resident Undocumented, in process 9. What is your sexual identity? Heterosexual, or straight Homosexual gay or lesbian Bisexual Asexual Fluid(ity) Other( please specify): I don t know the answer 2
3 PART 3: EMERGENCY CONTACT INFORMATION Relationship: Relationship: PART 4: PROFESSIONAL SUPPORTS Primary Care Physician Medical Facility/Clinic/Program: Psychiatrist Medical Facility/Clinic/Program: 3
4 Name (Primary contact): Therapist or Counselor or Case worker Counseling Service: PART 5: CURRENT MEDICAL & MENTAL HEALTH CONDITIONS Current Medical Conditions AIDS/HIV Cognitive Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Asthma Blood Disease Breathing Problem Cancer Chest Pain Clinical Obesity Convulsions Diabetes Dizziness or Fainting Spells Ear Problems/Hearing Loss Emphysema Epilepsy or Seizures Eye Problems Heart Attack/Failure Hemophilia Hepatitis (A,B or C) High Blood Pressure High Cholesterol Irregular Heartbeat Kidney Problems Liver Disease Low Blood Pressure Lung Disease Osteoporosis Stomach/Intestinal Disease Stroke Tuberculosis Ulcers 4
5 Part 5: CURRENT MEDICAL & MENTAL HEALTH CONDITIONS Current Mental Health Conditions Alcohol/Substance Abuse Anxiety Disorder Autism Spectrum Disorder (ASD)/ Asperger s syndrome Attention Deficit/Hyperactivity Disorder (ADHD/ADD) Bipolar Disorder Depression Dissociative Disorder Hoarding Disorder Illness Anxiety Disorder (IAD) Obsessive-Compulsive Disorder (OCD) Panic Disorder Personality Disorder (Borderline, Antisocial, etc.) Post-Traumatic Stress Disorder (PTSD) Schizophrenia Seasonal Affective Disorder (SAD) Sexual & Paraphilic Disorder Sleep & Wake Disorder (Insomnia, Narcolepsy, etc.) PART 6: ALLERGIES & MEDICATIONS Allergies & Reactions Current Medications 5
6 PART 7: INTEREST & GOALS Please explain your interest(s) in Recovery Services at the Center: Please explain your recovery goals and discuss what kind of help and support you think you will need to accomplish those goals: 6
7 PART 8: Authorization for Two-Way Release of Information for Medical and Psychiatric Records 1. Name of person/facility/agency other than or at Boston University to receive or release information: ***insert contact relationship and name 2. Information I give permission to release or receive 3. This release will expire on If nothing is specified, it will expire when I am no longer receiving services at Boston University. I understand that I have a right to withdraw this release at any time. If I withdraw this authorization, I must do so in writing and present it to the address above. I understand that if I pull my release of this information, it will not apply to information that has already been given before I withdrew this permission. I understand that once the above information is disclosed to a person, facility or agency outside Boston University, the person who receives this information may disclose it again and the information may not be protected by federal or state privacy laws or regulations. I understand that I may choose whether or not to sign this form and that I do not need to sign this form in order to receive rehabilitation and recovery services from Boston University and/or the other person, facility or agency. However, without the ability to share or obtain information, Boston University and/or the other person/agency may not be able to provide effective rehabilitation and recovery services. Your Signature or Personal Representative s Signature Date Print Name of Signer 7
8 Boston University College of Health & Rehabilitation Sciences: Sargent College Center for Psychiatric Rehabilitation Stephanie Cummings, Administrative Manager Recovery Services Division 940 Commonwealth Avenue West Boston, Massachusetts T F stephc13@bu.edu cpr.bu.edu Please have your primary care physician or psychiatrist complete this form, and fax it to Stephanie Cummings at (617) Patient s Full MEDICAL AND PSYCHIATRIC FORM Physician/Psychiatrist Full Medical Facility/Clinic/Program: Date of Last Examination/Assessment: Diagnoses: Full DSM or ICD-10 Code(s): Initial date of diagnosis: Date of Last Clinical Contact: Psychiatric or Other Medication(s) Please List Any Restrictions/Recommendations: Physician/Psychiatrist s Signature: Date 8
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Boston University College of Health & Rehabilitation Sciences: Sargent College Center for Psychiatric Rehabilitation Stephanie Cummings, Administrative Manager Recovery Services Division 940 Commonwealth
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:Maryann ~ssio, 'D.O.,.f.J\.5\.P. PATENT NFORMATON! Patient Name, Date of Birth_/ Address Home Phone. City State Zip Code Sex : Male Female Work Phone Cell Phone Email. Social Security # Marital Status
CURE CARDIOVASCULAR CONSULTANTS
NEW PATIENT PACKET There are six pages in this packet that will help us get a clearer picture of your medical history and physical health. Please note: SIGNATURES are required on pages 2, 4, and 6. Please
Ivis M. Getz, D.M.D. Caring For Kids Pediatric Dentistry, P.C. 140 Lockwood Avenue, Suite 315, New Rochelle, NY 10801
How did you hear of our office? New Patient Registration SECTION 1: PATIENT INFORMATION Patient Name: M / F Date of Birth: Address: City: State: Zip Code: SECTION 2: PARENT / GUARDIAN / INSURANCE Name:
The process has been designed to be user friendly and involves a few simple steps.
HOW DO I ENROLL A PATIENT WITH HOUSECALL MD? The process has been designed to be user friendly and involves a few simple steps. It is the patient s/family s/dpoa s/guardian s decision, if they want to
These documents contain the questions for the Illini Career and Internship Fair. At the University of Illinois at Urbana-Champaign
These documents contain the questions for the 2016 Illini Career and Internship Fair At the University of Illinois at Urbana-Champaign Questions are uploaded via CampusLabs and students fill out their
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Name: Date of Birth: Age: Address : Social Security #: City: Sex: Marital Status: State: Zip: Language: Pt Declines Home Phone#: Race: Pt Declines Work Phone#:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -