NEW PATIENT INQUIRY FORM

Thank you for your interest in scheduling a new patient appointment with our practice. To schedule your appointment as soon as possible, we request that all new patients submit a brief inquiry online. *If you are in crisis and need immediate care, please call 911 or go to your nearest emergency room.

Please be advised that we primarily provide medication management and only provide psychotherapy in conjunction with medication monitoring.

Any past psychiatric hospitalizations?

Any Family History of Schizophrenia?

History of suicidality or attempt

History of trauma

Do you have a primary care provider?

Do you have a therapist?

Do you have a mental health provider?

Do you have recent lab work within the past year?

Do you plan on using any health insurance?

Are you seeking FMLA? Please note that our provider will consider evaluation on a case by case basis for established clients only.

Are you seeking Short-Term Disability paperwork? It is important to note that we do not provide a one-time psychiatric evaluation for employment, medical clearance, disability, or legal matters, etc.

Time Preference