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?

Yes

In your own words, please tell us a little about what has been going on that you need help with. i'll cover the details during our face to face visit so don't worry about putting everything down or forgetting something. how long has it been going on? did something cause it or make it worse? how severe is it? does anything help you feel better? if so, what? do your symptoms come and go or are they constant? put down any other information that you think will help me get to know you better.

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?

Yes

Have you ever been psychiatricly hospitalized?

Yes

Alcohol & Drug History

Alcohol Use

None

Rarely

Sometimes

Often

I have tried to cut back on my drinking.

I have become angered or annoyed by others criticizing my drinking.

I feel guilty about my drinking.

I have gotten up in the morning and had a drink to steady my nerves.

Alcohol

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

MARIJUANA

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

COCAINE

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

CRYSTAL METH

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

ICE

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

ADDERALL

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

RITALIN

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

LSD

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

XTC/MOLLY

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

PEYOTE

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

KETAMINE

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

MUSHROOMS

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

XANAX

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

VALIUM

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

KLONOPIN

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

ATIVAN

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

DEXTROMETHORPHAN

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

STEROIDS

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

SPICE

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

BATH SALTS

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

For What?

Treatment

Finished treatment

Left early

For What?

Treatment

Finished treatment

Left early

For What?

Treatment

Finished treatment

Left early

Have you ever participated in 12-step recovery (aa/na)?

Yes

Do you currently participate in 12-step recovery?

Yes

Seamless Patient Intake Process

Streamlined Process for Your Care

Past Psychiatric History

Alcohol & Drug History

Past Medical History

Past Surgical History

Family History

Psychosocial history

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