New Patient Inquiry Form

New Patient Inquiry

Please complete the information below. Our office staff will call you to complete the intake process.
Patient's Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Parent's Phone Number

Area CodePhone Number
Parent Name

First NameMiddle NameLast Name
E-mail
Referred By:

First NameLast Name
Reason For Appointment:
Current Therapist:

First NameLast Name
Current Psychiatric Medications:
Current or Previous Medical Conditions:
Current or Past History of Substance Abuse?
Current or Past History of Physical Aggression?
Current or Past History of Self Harm?
Current or Past History of Suicidal Ideation?
Current or Past Diagnosis of Asperger’s/Autism?
Current or Past History of Psychiatric Hospitalization?
Type a question
By submitting and signing this form, I consent to abide by all office policies including agreeing to provide 72 business hours notice of cancellation for new patient evaluation. I understand that cancelling within 72 business hours will result in a charge to my credit card for the total cost of the evaluation.
Signature
Should be Empty: