Quiet Mind, LLC                                                                                      Today’s date: _________________
Michelle Roberts, FNP, PMHNP
1722 NW Raleigh St.  Suite 211  Mailbox 410
Portland, OR 97209             Phone: 971 . 282 . 2346      Fax:  971 . 228 . 1382    
Email: quietmindportland@gmail.com         
Client Information 

Identification 
Your name: ____________________________________________  Date of birth: __________________ Age: _______
Nicknames or aliases: _________________ Gender (circle one) : F / M / T  Social Security #: ______________________
Home street address: _______________________________________________________________ Apt.: __________
City: ___________________________________________________________  State: _______ Zip: _______________
Home Phone: _____________________________________ Email: _________________________________________
Cellphone: ______________________________ May I text you at this number? ❑ Yes    ❑ No
Please indicate any restrictions when communicating with you via phone, text, or email: _________________________
_______________________________________________________________________________________________
Martial Status (please circle one):   Married   /  Domestic Partnership  /   Divorced  /  Widowed  / Single  /    
Height: ___________    Weight: __________
Referral:  How did you find me?
Name: ________________________________________________________ Phone: _________________________
May I have your permission to thank this person for the referral?     ❑ Yes    ❑ No 
How did this person explain how I might be of help to you? ____________________________________________
____________________________________________________________________________________________
Other: ______________________________________________________________________________________

Your medical care: From whom or where do you get your medical care? 
Clinic's name: _______________________   Clinician's Name:_____________________  Phone: __________________
Would you like me to contact your provider so that we can coordinate your treatment?   ❑ Yes   ❑ No 

Your current employer 
Employer: ______________________   Occupation: ________________  Your Work phone: _____________________
Do you want to be contacted at this number? ❑ Yes  ❑ No   /    Can I leave a message at this number? ❑ Yes  ❑ No  
Please indicate any restrictions: _____________________________________________________________________

Emergency information

If some kind of emergency arises and we cannot reach you directly, or we need to reach someone close to you, whom should we call?
Name: ______________________________ Phone: ____________________ Relationship to you: ________________
Name of nearest friend or relative not residing with you: ___________________________________________________
Relationship to you: ___________________  City & State: ___________________Phone:________________________ 

Insurance Information
Insurance Company Name: _______________________________________________________________________
Policy #: ________________________    Group #: ________________________  Group Name: ________________
Location of Plan: _______________________________________________________________________________
Primary Insurance Company Address: ______________________________________________________________
Insurance Address / PO Box: ______________________________________________________________________
City: ________________________________  State: ____________  Zip Code: ______________________________ 
Phone for Providers: _________________________  Behavioral Health Phone: ______________________________

If you are not the subscriber of the insurance plan, please complete this section:
Name of Subscriber: ____________________________________________________________________________
Your Relationship to Subscriber:   Spouse    /   Domestic Partner   /    Child   /   Other: ________________________
Subscriber's DOB: __________________Subscriber's Social Security #: ___________________________________  

Subscriber's Home Address: _______________________________________________________________________
City: ______________________  State: ________  Zip Code: ___________ Phone: ___________________________
Email: _________________________________________________________________________________________

_______________________________________________________________________________________________

Secondary Insurance Company Name: ______________________________________________________________
Secondary Insurance Company Address / PO Box: _____________________________________________________
City: ________________________________  State: ____________  Zip Code: ______________________________ 
Phone for Providers: _____________________________  Behavioral Health Phone: __________________________
 
If you are not the subscriber of the insurance plan, please complete this section:
Name of Subscriber: ____________________________________________________________________________
Your Relationship to Subscriber:   Spouse    /   Domestic Partner   /    Child   /   Other: ________________________
Subscriber's DOB: __________________Subscriber's Social Security #: ___________________________________  
Policy #: ________________________    Group #: ________________________  Group Name: _________________
Location of Plan: ________________________________    Phone #: _______________________________________

Subscriber's Home Address: _______________________________________________________________________
City: ______________________  State: ________  Zip Code: ___________ Phone: ___________________________
Email: _________________________________________________________________________________________