Clinical Info
Has another provider referred you to our office or are you self-referred? Please note who has referred you for services *
What type of services are you seeking? (ex: medication management, psychological testing, individual therapy)
Are you currently ordered to participate in mental health services by court or legal order? *
Please provide a brief summary of the nature of the problem(s) for which you are seeking treatment *
How long have these concerns been problematic? *
What mental health services have you utilized in the past? Please estimate when you were last participating in these services *
Please list approximate dates of all previous psychiatric hospitalizations *
Have you ever attempted suicide? If so, when? *
Please list active psychiatric medications *
Please list previous psychiatric medications that were not helpful for your treatment *
Please list active medical concerns for which you are currently being treated and/or evaluated, as well as if you are actively pregnant *
Please list active non-psychiatric medications that are currently prescribed to you *
Are you on disability? If so, for how long have you been on disability and for what conditions have you been awarded disability previously? *
Please provide a brief employment history, including current position of employment, if applicable *
Are you currently involved in any legal proceedings, including custody arrangements, including custody proceedings? Please note any ongoing/pending legal proceedings *
How often do you consume alcohol? *
Do you have a history of problematic alcohol consumption? *
How often do you consume nicotine or tobacco products? *
Do you have a history of problematic nicotine or tobacco consumption? *
How often do you consume marijuana/cannabis/THC? *
Do you have any history of problematic consumption of marijuana/cannabis/THC? *
Do you have any history of other recreational substance use? Please identify notable substance use patterns *
Do you prefer working with a male or female provider? (We will do our best to accommodate preferences, though can not ensure this preference to be met) *
Please let us know if there are any other considerations of which you would like our staff or providers to be aware when attempting to establish the best services possible for your case *
Please provide an emergency contact information (including name, relationship to the patient, and phone number) in the instance that providers/staff need to seek urgent communication and/or care. *
Scheduling Info
Are there any times that would NOT work for scheduling an appointment? *
If your insurance plan is accepted by the clinician, what is the policy ID number? For private pay, enter 'n/a'. *
Insurance Group number: *
Insurance Policy number: *
Our office accepts some, but not all, forms of Medicaid. If you are using Medicaid insurance, please specify the type of Medicaid being used: *
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