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Pre-Admit Form

Excelsior Psychological Services
11111 Hall Rd. Suite 105
Utica, Michigan 48317
Phone (248) 656-5003
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Identifying Information
Who is calling?
Identifying Information:
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
Email:
Date of Birth
Social Security Number
Referral Source:
Online  
Insurance Company  
ER  
Pain Management  
Physician's Office  
Other  
Is it ok to receive mail at this address from EPS?
Yes  
No  
Language
Race
Veteran?
Marital Status
General Status
Disabled   Employed   Refused  
Retired   Senior   Student  
Unemployed - Seeking Employment   Unemployed - Unable to Work   Other:  
GENERAL
What are the concerns that bring you here today?
Have you received assistance from us before?
Are you looking for:
Therapy  
Medication Treatment  
Other:  
Are you currently working?
Where are you working?
Are you currently taking any medications?
Yes   No    
If yes, which medications?
Is alcohol or substance use an issue for you now?
Yes   No    
If yes:
Insurance and Financial Information
Insured?    Does the patient have insurance?
Insurance Name:
Insurance Address:
Insurance City, State and ZIP:
Insurance Phone:
Policy Number:
Group Number:
Medicare Number:
Medicaid Number:
Date of Injury:    If applicable
Which method do you prefer for appointment reminders?
What number should EPS use? (If different from above)
Signature:
Signer Type: NextStep User
  Client (Please click "Sign with Topaz" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Topaz" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Topaz
If you are filling this form out online, you will sign this form upon arrival to our office.
Form Updates
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