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info@aonebhs.com
6188 Oxon Hill Rd #601, Oxon Hill, MD 20745
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Conditions We Treat
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Contact Us
Home
About Us
Providers
Services
Telehealth
Conditions We Treat
Patient Resources
Careers
Contact Us
Free Consultations
(240) 553-7993
Online New Patient Forms
Home
Online New Patient Forms
Online New Patient Forms
SECTION 1 – CONTACT & DEMOGRAPHICS
Last Name
First Name
Middle Initial or Name
SSN # (optional)
Birth Date
Age
Height – Feet
Height – Inches
Weight (lbs)
Gender
Male
Female
Non-binary
Address
City
State
Zip
Best Contact Phone Number
Messages OK?
Text
Voice
Email
Highest Level of Education
Employment / Student Status
Employed
Unemployed
Student
Occupation
Employer / School
Relationship Status
Married
Single
Divorced
Separated
Dating
Prefer not to specify
Race
American Indian or Alaskan Native
Asian
Black/African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White or Caucasian
Number of Children
Emergency Contact
Name
Relation to Client
Best Contact Phone Number
Insurance Information
Insurance Company
Insured Name/Responsible Party
Member ID
Effective Date
DOB
Relationship
Self
Spouse
Father
Mother
Upload Insurance Documents
Insurance Card (Front)
Insurance Card (Back)
Government-issued ID
Other Insurance Documents (Multiple allowed)
SECTION 2 – CONSENT & AGREEMENTS
Consent & Agreements
HIPAA Notice of Privacy Practices Acknowledgement
Treatment Agreement & Patient Responsibilities
Prescription / Medication Agreement (if applicable)
Telehealth & Electronic Communication Consent
Transcription & Documentation Consent
Client Signature (type full name)
Date
SECTION 3 – PHQ-9 Depression Screening
1. Little interest or pleasure in doing things
Not at all
Several days
More than half the days
Nearly every day
2. Feeling down, depressed, or hopeless
Not at all
Several days
More than half the days
Nearly every day
3. Trouble falling/staying asleep, or sleeping too much
Not at all
Several days
More than half the days
Nearly every day
4. Feeling tired or having little energy
Not at all
Several days
More than half the days
Nearly every day
5. Poor appetite or overeating
Not at all
Several days
More than half the days
Nearly every day
6. Feeling bad about yourself
Not at all
Several days
More than half the days
Nearly every day
7. Trouble concentrating
Not at all
Several days
More than half the days
Nearly every day
8. Moving/speaking slowly OR being restless
Not at all
Several days
More than half the days
Nearly every day
9. Thoughts of self-harm
Not at all
Several days
More than half the days
Nearly every day
SECTION 4 – GAD-7 Anxiety Screening
1. Feeling nervous, anxious, or on edge
Not at all
Several days
Over half the days
Nearly every day
2. Not able to stop or control worrying
Not at all
Several days
Over half the days
Nearly every day
3. Worrying too much about different things
Not at all
Several days
Over half the days
Nearly every day
4. Trouble relaxing
Not at all
Several days
Over half the days
Nearly every day
5. Restless; hard to sit still
Not at all
Several days
Over half the days
Nearly every day
6. Easily annoyed or irritable
Not at all
Several days
Over half the days
Nearly every day
7. Feeling afraid something awful might happen
Not at all
Several days
Over half the days
Nearly every day
SECTION 5 – SBQ-R Suicide Risk Questionnaire
1. Ever thought about or attempted suicide?
Never
Brief passing thought
Had a plan but did not try
Had a plan and wanted to die
Attempted but did not want to die
Attempted and hoped to die
2. Frequency of thoughts in past year?
Never
Rarely (1 time)
Sometimes (2 times)
Often (3–4 times)
Very often (5+)
3. Ever told someone you might attempt?
No
Yes once (not serious)
Yes once (serious)
More than once (not serious)
More than once (serious)
4. Likelihood you will attempt in future?
Never
No chance at all
Unlikely
Likely
Rather likely
Very likely
SECTION 6 – MDQ Mood Disorder Questionnaire
1. Felt extremely good / hyper
Yes
No
2. Very irritable; arguments or fights
Yes
No
3. Higher self-confidence
Yes
No
4. Needed less sleep
Yes
No
5. More talkative
Yes
No
6. Racing thoughts
Yes
No
7. Easily distracted
Yes
No
8. More energy
Yes
No
9. More active
Yes
No
10. More social / outgoing
Yes
No
11. Increased sexual interest
Yes
No
12. Unusual / risky behavior
Yes
No
13. Spent money excessively
Yes
No
Did several YES answers occur during same period?
Yes
No
How much of a problem did these cause (impairment)?
No problem
Minor
Moderate
Serious
Family history of bipolar disorder?
Yes
No
Ever diagnosed with bipolar disorder?
Yes
No
SECTION 7 – FINAL SIGNATURES
Patient Name
Patient Signature
Representative Name (if applicable)
Relationship to Patient
Representative Signature
Provider Name
Provider Signature
Date
Submit Intake Form
