• Medication Management Intake Survey

  • We are glad you are interested to select Acacia as your Psychiatry Provider. We'd love to get to know you a little better. 

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Past Diagnoses

  • Over the last 2 weeks, how often have you been bothered by any of the following problems?

  • Little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless?
  • Trouble falling/staying asleep, sleeping too much
  • Feeling tired or having little energy?
  • Poor appetite or overeating?
  • Feeling bad about yourself — or that you are a failure or have let yourself or your family down?
  • Trouble concentrating on things, such as reading the newspaper or watching television?
  • Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
  • Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?
  • Feeling nervous, anxious, or on edge?
  • Not being able to stop or control worrying?
  • Worrying too much about different things?
  • Trouble relaxing?
  • Being so restless that it's hard to sit still?
  • Becoming easily annoyed or irritable?
  • Feeling afraid as if something awful might happen?

  • Other Providers

    Great job so far! This next section is lets us know a bit more about your past providers. As with all sections, the more information you share, the better and faster we can answer your questions, but it is not required.
  • Have you seen a therapist / counselor in the last few years?
  • Do you have a current or recent psychiatrist (MD who prescribes meds)?
  • Do you have a current or recent primary care provider?
  • Often it's very helpful in giving you the best care for your providers to communicate and collaborate. We'd love to be able to understand as much as we can about what you've been through and the perspectives of your other doctors / providers, including information about your mental health. May Acacia Mental Health obtain information about your past care from the providers you listed above?
  • If we do treat you, it is often also helpful to communicate with your providers moving forward. May Acacia Mental Health communicate about your medical and mental health care with the providers listed above?

  • Next, we'll ask you more about your past antidepressants (up to 6). We understand it can be hard to remember details, and all of this will be confirmed with a physician before any decisions are made. Approximate answers (especially on dates) are just fine. Start from the medication you started most recently, and work your way back in time.

  • Medication #1

    The following questions will be about the medication you started MOST RECENTLY.
  • Is this a current medication?

  • Medication #2

    The following questions will be about the medication you started second-most recently.
  • Is this a current medication?

  • Medication #3

    The following questions will be about the medication you started second-most recently.
  • Is this a current medication?

  • Medication #4

    The following questions will be about the medication you started second-most recently.
  • Is this a current medication?

  • Medication #5

    The following questions will be about the medication you started second-most recently.
  • Is this a current medication?

  • Medication #6

    The following questions will be about the medication you started second-most recently.
  • Is this a current medication?
  • Are you currently taking a benzodiazepine like lorazepam (Ativan), clonazepam (Klonopin), alprazolam (Xanax), or diazepam (Valium)?
  • What benzodiazepine are you taking?

  • Have you had any of the following (even once)? These are not necessary rule-outs for TMS.
  • Which of the following best describes how much you drink alcohol?
  • Which of the following best describes how often you consume cannabis?
  • Which of the following best describes how often you use other "hard" drugs (hallucinogens, meth, heroin, etc.)?

  • Financial Information

  • While we would like to focus on the clinical aspects of care, we realize that finances can be a barrier. In order to minimize delays in care, we give you the option of giving insurance information.

  • Would you like to apply for financial aid / sliding scale rates? We consider granting these rates when individuals or their primary caregiver make < $200,000 / year.

  • Please answer the following questions for the household financially responsible for you (e.g. if a spouse financially supports you, please answer for your hosehold; if you parents support you, please answer for them). Approximations on the following numbers are acceptable. We may request documentation (e.g. IRS 1040 from a previous year) to verify these numbers.

  • Do you have insurance?
  • Insurance Card - Front
  • Insurance Card - Back
  • Should be Empty: