Patient Form

Seamless Patient Intake Process

Streamline your care by completing our patient intake form – your first step towards tailored mental health support

Patient Form Submission

Streamlined Process for Your Care

Complete our patient form conveniently and efficiently. Your details will help us tailor our care to meet your unique mental health needs. Start your journey towards improved well-being by filling out our user-friendly patient form

Does anyone else live in the same home with you?

Past Psychiatric History

Please list any other person who has been providing or has provided mental health care for you and when you were under their care. This may be another psychiatrist, a psychologist, social worker, school counselor, individual therapist, marital therapist, minister, priest or pastoral counselor. You should include anyone who has prescribed psychiatric medication for you (primary care provider, obgyn, family nurse practitioner, other health care provider.

List all current medications, dosage, instructions, who prescribes them and what you take them for

Have you ever attempted suicide?
Have you ever been psychiatricly hospitalized?

Alcohol & Drug History

Alcohol Use

Alcohol

MARIJUANA

COCAINE

CRYSTAL METH

ICE

ADDERALL

RITALIN

LSD

XTC/MOLLY

PEYOTE

KETAMINE

MUSHROOMS

XANAX

VALIUM

KLONOPIN

ATIVAN

DEXTROMETHORPHAN

STEROIDS

SPICE

BATH SALTS

Treatment
Treatment
Treatment
Have you ever participated in 12-step recovery (aa/na)?
Do you currently participate in 12-step recovery?

Past Medical History

Past Surgical History

Family History

Psychosocial history

Did anyone ever physically abuse you?
Did anyone ever emotionally abuse you?
Did anyone ever sexually abuse you?
Are you employed?
Are you medically disabled?
What is your sexual preference?
Are you currently involved in a lawsuit?