New Patient Enrollment Form
Call today for more information: 412-668-4444
Which Location are you seeking treatment at?
What type of treatment are you seeking?
Psychiatric Med Management
Substance Use Disorder Treatment
Date of birth:
What is your gender?
Street Address Line 2
State / Province
Postal / Zip Code
Are you currently active in treatment at Journey Healthcare?
Please Select Current Symptoms
Self-injurious behavior (e.g., cutting, picking)
Ritualistic thoughts and/or behaviors
Elevated or euphoric mood
Hearing voices or noises others can't hear
Upset stomach / Nausea
Talking or moving slowly
Decreased need for sleep
Inability to work
Excessive alcohol use
Excessive substance use
Seeing people or things that others can't see
Substance Abuse History - Have you ever considered yourself to have a problem with alcohol or drugs?
Please list substance use including substance type and frequency of use.
Do you have any medication allergies or known allergies?
Please list them.
Do you have any metal objects or implantable devices in or around the head (e.g., cardiac defibrillator/pacemaker, insulin pump).
If yes, please list Medical objects.
If yes, specify medical diagnosis?
If yes, specify recent surgeries:
Medication (past and present)
Check all medication tried.
Antidepressants: (From the list below, please check both current and previous medications tried).
Prozac (fluoxetine) - SSRI
Luvox (fluvoxamine) - SSRI
Celexa (citalopram) - SSRI
Effexor (venlafaxine) - SNRI
Tofranil (imipramine) - TCA
Vivactil (protriptyline) - TCA
Emsam (selegiline) - MAOI
Nardil (penelzine) - MAOI
Pristiq (desveniaflaxine) - SNRI
Wellbutrin (bupropion) - NDRI
Viibryd (vilazodone) - SM
Oleptro (Trazodone) - SM
Pamelor (nortriptyline) - TCA
Zoloft (sertraline) - SSRI
Paxil (Paroxetine) - SSRI
Lexapro (Escitalopram) - SSRI
Fetzima (levomilnacipran) - SNRI
Elavil (amitriptylie) - TCA
Remeron (mirtazapine) - TeCA
Marplan (isocarboxazid) - MAOI
Parnate (traylcpromine) - MAOI
Cymbalta (duloxetine) - SNRI
Serzone (nefazodone) - SM
Trintellix (vortioxetine) - SM
Anafranil (clomipramine) - TCA
Anti-psychotics / Mood stabilizers
Sedative / Hypnotics
ADHD / Stimulants:
Please specify which medications you are currently taking at this time:
List only the medications you are currently prescribed and taking at this time. Please indicate dose and frequency.
By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Journey Healthcare LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.*
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