Health Screening and Medical History

ATTENTION - PLEASE READ

StarCare Specialty Health System does not prescribe stimulants (including but not limited to Adderall, Vyvanse, Ritalin) or benzodiazepines (including but not limited to Xanax, Klonopin, Valium, Ativan).

Medication management resources outside of StarCare can be found by calling 211 Texas (dial 2-1-1) or visit their website at https://www.211texas.org.

If you are experiencing a mental health crisis, call 806-740-1414 or 800-687-7581.

StarCare Specialty Health System takes all necessary steps to ensure Health Insurance Portability and Accountability Act (HIPAA) compliance. For more information, click the "Privacy Notice" link at the bottom of this form.

Instructions for Completing Intake Forms

Complete the following information for the person seeking services with StarCare Specialty Health System. If a question is not applicable, enter “N/A” in the space provided.

Completing this information ahead of time will shorten the time needed to complete your intake. Upon completion of the intake process, if eligible, you will be authorized for services based on your need. You will be assigned a case manager to assist you with accessing needed resources and services.

Before beginning this form, it is recommended you gather and have the following information available, if applicable:

Name of Primary Care Physician
List of past and current medical conditions

First Name

Middle Name

Last Name

Suffix

Date of Birth

mm/dd/yyyy

Health Screening

Name of Primary Care Provider (PCP)

When was the last time you saw your Primary Care Provider (PCP)?

mm/dd/yyyy

Are you allergic or sensitive to any medications?

Yes

Height

Weight

Are you currently pregnant or think you might be pregnant?

Yes

Unknown

Not applicable

Are you currently breastfeeding?

Yes

Not applicable

Medical History

Is there any additional information we need to know about you or your medial needs at this time?

By typing my full name below, I certify the information provided is true and complete to the best of my knowledge. I understand typing my name is a legal signature and is considered the same as my handwritten signature.

Electronic Signature - Full Name of Person Completing this Form

Date Signed

mm/dd/yyyy

Send me a copy of my responses

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