California Center for Behavioral Health

925 Ygnacio Valley Road, Ste 205, Walnut Creek, CA 94596(925) 289-9022Fax (888) 965-0556

New Patient Intake Questionnaire

Please complete this questionnaire so Dr. Sekhon's team can prepare for your first visit. It has 16 sections. Have your insurance card and a list of your current and past medications ready. Your answers are not saved until you press Submit.

Please note: Submitting this form does not initiate care or establish a doctor-patient relationship. Our team will review your submission and reach out to schedule. This form is not monitored in real time. If this is an emergency, call 911, or call or text 988 (Suicide & Crisis Lifeline).

JavaScript is required to submit this form online. Please enable JavaScript, or download the printable PDF from the New Patient Forms page and fax it to (888) 965-0556.

1. Patient Information

Full Name

Date of Birth

Address

City

State

ZIP Code

Cell Phone

Home Phone

Height

Weight

2. Insurance

Insurance Carrier

Insurance Phone

Insurance ID

Group #

Primary Insured Name

Primary Insured DOB

Primary Insured Address (if different from yours)

3. Emergency Contact

Name

Relationship

Cell Phone

Home Phone

4. Care Team

Primary Care Doctor

PCP Phone

Therapist / Psychologist

Therapist Phone

5. Reason for Visit / Symptoms

What brings you in? Please describe your symptoms and what you're hoping to address.

6. Sleep

Typical bedtime

Typical wake time

Estimated total sleep (hours per night)

Snoring or witnessed apnea?

Yes No Unsure

Daytime sleepiness?

Yes No

7. Past Psychiatric History

If you are having thoughts of harming yourself or someone else right now, call or text 988 (Suicide & Crisis Lifeline), or call 911 if you or someone else is in immediate danger. This form is not monitored in real time.

If anything below applies, check Yes and add detail in the box below.

Past suicidal thoughts?

Yes No

Past suicide attempts?

Yes No

Past self-harm behaviors?

Yes No

Past psychiatric hospitalizations?

Yes No

If yes to any of the above, please describe (when, where, circumstances)

8. Therapy History

Current or past therapy — provider, dates, type of therapy

9. Previous Psychiatric Medications

Medications you've tried in the past for mental health.

Medication	Dose	Dates	Effect / Reason Stopped

10. Medical

Current medical problems / diagnoses

11. Reproductive Health

If applicable.

Currently pregnant?

Yes No N/A

Planning pregnancy in the next year?

Yes No N/A

Currently breastfeeding?

Yes No N/A

Using contraception?

Yes No N/A

If yes, what method?

12. Current Medications

All medications you currently take, including over-the-counter and supplements.

Medication	Dose	Reason / Diagnosis	Duration

13. Allergies

Medication allergies and reaction (write "None" if applicable)

14. Substance Use

Current or past — please be as accurate as you can.

Substance	Currently using?	How much / how often	Last use	Problems caused
Alcohol
Tobacco / Nicotine
Cannabis
Caffeine
Other drugs

Other drugs used — please list names

15. Family Psychiatric History

Mental health diagnoses, suicide, or substance use in biological family members

16. Personal History

Where were you raised?

Family structure (parents)

Highest education

Siblings (ages)

Marital status

Significant other

Ages of children (if applicable)

Occupation

Years at current job

Work or school problems (if any)

Arrest history (if applicable)

Attestation & Signature

I attest that the information provided in this questionnaire is accurate to the best of my knowledge.

Patient / Guardian Signature (type full name)

Date

Language assistance and accessible formats

Free language assistance services, and free auxiliary aids and services such as qualified interpreters and information in accessible formats, are available to you. Call (925) 289-9022 (TTY: 711) or ask our staff. See our notice of nondiscrimination.