new patient intake | Brain Health USA

Name *

First

Last

Date Of Birth

Phone number *

Email

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Please upload Copy of ID (Driver License/Passport)

Click or drag a file to this area to upload.

Please upload Front and back of the Insurance card

Click or drag files to this area to upload.

You can upload up to 2 files.

Please upload Front and back of the pharmacy card

Click or drag files to this area to upload.

You can upload up to 2 files.

Do you have secondary insurance?

Yes
No

Social Security

Intake Questions

Which state do you reside? *

CA
Other state

Ketamine is a breakthrough psychedelic medication treatment for depression, anxiety, and trauma.
Even when other medicines have failed. Ketamine was proven to be the Fastest Acting Antidepressant; it creates Mental rest and relief within 24 to 72 hours after your first treatment because it builds new connections between neurons.
Chronic stress weakens neural connections in the brain over time.
Depression decreases the number of synapses – the connections between neurons – in the brain.  
Ketamine works directly to restore these connections. It binds to the NMDA receptor and releases a glutamate surge.
This in turn releases growth factors, like BDNF (brain derived neurotrophic factor), which help make new synaptic connections and pave healthier thought patterns in the brain.

Benefits Of Ketamine Therapy

The American Psychiatric Association confirms ketamine is rapid and robust antidepressant after reviewing dozens of clinical trials, proven to be safe and effective.
Ketamine works differently than traditional antidepressants and is often effective when SSRIs fail to work.
Ketamine produces profound and rapid antidepressant effects in one to four hours upon usage
Evidence from the National Institute of Health compelled the Cleveland Clinic to call ketamine a top 10 medical innovation.
There have been dozens of high-quality clinical trials demonstrating ketamine’s 60-90% response rate – even in treatment-resistant depression. What is “treatment-resistant?” These are people who failed two adequate trials of traditional anti-depressants.

Unfortunately, ketamine is not covered by insurance, if you are interested, please press yes and our ketamine specialist coordinator will contact you to share the packages with you.

Date / Time

Date

Time

Do you attend the regional center for autism or intellectual disability? *

YES
No

Height

5:11

Weight

190

Intake Questions

Please explain

Blood Pressure

Low
Normal
High

Medical History

Main Reason for seeking mental health services?

Evaluation/Consultation
Medication Management

Are you currently taking medication? *

YES
NO

Were you previously taking any medication.

YES
NO

Have you ever been hospitalized for any psychiatric reasons?

YES
NO

Does any of your immediate family have a history of psychiatric diagnoses that you know of?

YES
NO

Any Medication Allergies?

YES
NO

Any Past Surgeries?

YES
NO

Do you have any pending or past legal problems?

YES
NO

Do you have any eating disorder?

YES
NO

Have you ever had a DUI?

YES
NO

Have you ever had any head injuries or seizures?

YES
NO

Have you ever had any physical, sexual or mental abuse as a child or as an adult?

YES
NO

Social History

Do you use drugs including Cannabis/Weed/Marijuana? *

YES
NO

Do you smoke Tobacco or Vape?

YES
NO

Do you drink alcohol? *

YES
NO

Have you ever been to a drug/alcohol rehab?

YES
NO

Currently working?

YES
NO

Would you feel comfortable sharing your ethnicity?

YES
NO

Would you feel comfortable sharing your religion or spirituality?

YES
NO

Preferred Language of communication?

English
Spanish
Other

What are your hobbies or interests?

Example: Reading-hiking-watching movies- spending time with my family

Family History

Number of children?

Number of siblings?

How would you describe your relationship with your family?

Your current living situation?

Example: I live with my wife and children

On average how many hours do you sleep per day?

Example: 7 to 8 hours a day

Appetite?

Poor
Normal
Big
inconsistent

What's your treatment goal? *

Example: To be able to cope with my stress and figure best treatment plan for my ADHD.

Are you looking to get any paperwork/form filled out?

Yes
No

We are sorry to inform you the required forms will require to have complete disability, and is not approved for mental health disorders.

We are sorry to inform you the required forms will require to have complete disability, and is not approved for mental health disorders.

We are sorry to inform you the required forms will require to have complete disability, and is not approved for mental health disorders.