New Patient Inquiry New Patient Inquiry Form Please fill out the form below as completely as possible. About YouName(Required) First Last Address Street Address Address Line 2 City ZIP Code Email Address(Required) Phone Number(Required)Date of Birth(Required) MM slash DD slash YYYY Insurance InformationWill you be using insurance or be self-pay?InsuranceSelf-PayIf using insurance, which insurance do you have?If using insurance, which insurance, what is your Member Id?Patient HistoryAre you seeking medication, therapy, or both?(Required)MedicationTherapyBoth Medication & TherapyWhat is the reason you are seeking treatment?If you are leaving your current provider, is there a specific reason why? Please explain.Please list all current medications AND their doses.Have you been hospitalized in the last year for a mental health issue? If so, please tell us about that hospitalization.Do you have any current medical problems? If so, please explain.Have you ever been diagnosed with a personality disorder?(Required)YesNoHave you been diagnosed with Schizophrenia?(Required)YesNoAre you seeking evaluation or treatment for ADHD?(Required)YesNoIf yes, have you had formal psychiatric testing?(Required)YesNoAre you seeking treatment to be evaluated for disability benefits?(Required)YesNoAre you currently taking benzodiazepines (such as Xanax, Ativan, Valium, or Klonopin)?(Required)YesNoAre you currently taking opiates (narcotic pain medications)?(Required)YesNoAre you seeking treatment for substance use (Suboxone, Vivitrol, etc)?(Required)YesNoAre you currently using substances (Cocaine, Heroin, Meth, etc)?(Required)YesNoAre you seeking treatment in relation to a legal issue? Please explain. (examples: DWI, divorce, or child custody)How did you hear about us?AcknowledgementThis application for an appointment will not establish a provider/client relationship until you have an appointment. (By acknowledging, I understand this does not establish a provider/client relationship until l have an actual appointment and have seen the provider for an appointment.)(Required)YesNoThird ChoiceCAPTCHADate MM slash DD slash YYYY
