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 Name Middle Name Last Name
Date of Birth *

Month Day Year
Phone Number *

Area Code Phone Number
Parent Name *

First Name Middle Name Last Name
E-mail *
Referred By: *

First Name Last Name
Referred By Friend Internet Search
Reason For Appointment: *
Current Therapist: *

First Name Last Name
No Current Therapist Prefer Not To Say
Current Psychiatric Medications: *
Current or Previous Medical Conditions: *
Current or Past History of Substance Abuse? *

Yes No
Current or Past History of Self Harm? *

Yes No
Current or Past History of Suicidal Ideation? *

Yes No
Current or Past Diagnosis of Asperger’s/Autism? *

Yes No
Current or Past History of Psychiatric Hospitalization? *

Yes No
Type a question
By submitting and signing this form, I consent to abide by all office policies including agreeing to provide 48 business hours notice of cancellation for new patient evaluation. I understand that cancelling within 48 business hours will result in a charge to my credit card for one half the total cost of the evaluation.
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