New Patient Appointments
Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you!
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please select on of the following
*
Adult
Child
Referred by
*
Name of person completing form
*
First Name
Last Name
Relationship to patient
*
Patient's Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Home Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Will you be using insurance or be self pay?
Insurance
Self Pay
If you have insurance,
Rows
What is the name of the insurance company?
What is the member ID?
What is the group Number?
What is the provider services phone number?
Reason for Appointment?
*
Are you currently seeing a therapist/counselor?
*
Yes
No
if yes, What is the name of the therapist/counselor you are seeing?
How long have you been under their care?
List current psychiatric medications you are taking, including over the counter andsupplements. Please include, name, strength, and the directions to take.
Are you currently being court ordered to seek mental health care?
*
Yes
No
Are you seeking medical leave or currently on medical leave?
*
Yes
No
Have you had any previous psychiatric hospitalizations?
*
Yes
No
If yes, how many times? When was the last time? And the reason?
When you were hospitalized was it:
Voluntary
Involuntary
Do you have any eating disorders?
*
Yes
No
If yes, is it currently active or in the past?
Do you suffer from alcohol or substance abuse?
*
Yes
No
If yes, what substance/s and how long ago was the last time used?
Are you having suicidal thoughts?
Yes
No
Are you having thoughts of harming others?
Yes
No
Are you aggressive?
Verbally
Physically
Both
None
Is there family history of mental illness?
Yes
No
If yes, please state who, and what mental illness they have.
Submit
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