New Patient Form

Today's Date (required)

Your Name (required)

Patients name (required)

Patients date of birth (required)

Your email (required)

Your address (required)

Your phone number (required)

Preferred method of contact: by phone or email.

Service requested: Individual counseling, Family or Couples counseling, Medication consultation.

What time of day are you able to attend appointments? Please note that evening availability is limited.

Reason for seeking services.

Insurance company (required)

Policy number (required)

Subscribers name (required)

Please answer the following questions to the best of your ability.

Has the patient ever been hospitalized for psychiatric reasons?(required)

If the answer is yes, please explain:

Does the patient have any issues with drugs or alcohol?(required)

If the answer is yes, please explain:

Is the patient currently taking an psychiatric medications? (required)

If the answer is yes, please list medications, dosage and name of the prescriber.

Are the services the patient is seeking regarding a workplace or automobile accident? (required)

Are the services the patient is seeking related to a legal matter? (required)

Is the patient involved in a custody situation? (required)