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 NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Parent's Phone Number*

Area CodePhone Number
Parent Name*

First NameMiddle NameLast Name
E-mail*
Referred By:*

First NameLast Name
Referred By FriendInternet Search
Reason For Appointment:*
Current Therapist:*

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

YesNo
Current or Past History of Physical Aggression?*

YesNo
Current or Past History of Self Harm?*

YesNo
Current or Past History of Suicidal Ideation?*

YesNo
Current or Past Diagnosis of Asperger’s/Autism?*

YesNo
Current or Past History of Psychiatric Hospitalization?*

YesNo
Type a question
By submitting and signing this form, I consent to abide by all office policies including agreeing to provide 72 business hours notice of cancellation for new patient evaluation. I understand that cancelling within 72 business hours will result in a charge to my credit card for the total cost of the evaluation.
Signature

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