Inquiry Form

New patient inquiry form.

About You

Name(Required)

First Last

Address

Street Address Address Line 2 City ZIP Code

Email Address(Required)

Phone Number(Required)

Insurance Information

Will you be using insurance or be self-pay?

If using insurance, which insurance do you have?

If using insurance, which insurance, what is your Member Id?

Patient History

Are you seeking medication, therapy, or both?(Required)

What 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)

Have you been diagnosed with Schizophrenia?(Required)

Are you seeking evaluation or treatment for ADHD?(Required)

If yes, have you had formal psychiatric testing?(Required)

Are you seeking treatment to be evaluated for disability benefits?(Required)

Are you currently taking benzodiazepines (such as Xanax, Ativan, Valium, or Klonopin)?(Required)

Are you currently taking opiates (narcotic pain medications)?(Required)

Are you seeking treatment for substance use (Suboxone, Vivitrol, etc)?(Required)

Are you currently using substances (Cocaine, Heroin, Meth, etc)?(Required)

Are you seeking treatment in relation to a legal issue? Please explain. (examples: DWI, divorce, or child custody)

How did you hear about us?

Acknowledgement

This 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)

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