WUOTT – Waking Up on the Toilet
Sat (8:30AM - 4PM)
El Cajon, CA 92021
Drop us a line
Full Name:
DOB:
Lebal Guardian:
Phone#.
Email:
Are you the Emergency Contact? YN
If no Emergency contact:
Annual Household Income:
Is patient Insured? YN
Insurance Type:
Member ID Number
Sponsor SSN:
(Please be sure to attach a copy of Insurance Card and State ID or DL up on completion of intake form)
Any history of Mental/Behavioral Health Issues? YN (circle one)
If yes, explain:
Are you the Victim of a Crime (VOC)? YN
If Yes, Do you have an incident Number ?
Medications Being Taken:
Tobacco Use? YN
If yes, how often:
Alcohol consumer? YN
Recreational Drugs? YN
Have you ever been prescribed ADHD medications? YN
Are you currently seeking medication management for ADHD? YN
General Reason For Visit?
(Note: there is a $50 charge for ALL LATE OR MISSED APPOINTMENTS to be paid by the patient not their insurance provider)
Special Concerns or Questions?
Client Signature
Upload Photo ID And Insurance Card*
Date: