New Patient Inquiry FormInterested in becoming a new patient? Please complete this form, and a staff member will contact you. Name * First Name Last Name Date of Birth * MM DD YYYY Age * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Mobile Phone Number * (###) ### #### Gender * Employment Status * If employed, list the name of your employer, full-time or part-time status, and your occupation/job title. Work Phone Number Marital Status * Single Married Separated Divorced Widowed Life Partner Health Insurance Company * Health Insurance ID Number * Health Insurance Group Number Health Insurance Subscriber: Name, Date of Birth, and and Relationship to you * Are you currently a student? * Yes No Name of Institution Who referred you to us? * Name of Primary Care Physician * Phone Number of Primary Care Physician * Name of Therapist and Start Date (If you currently have one) Current Psychiatric Medications * Please include name(s) of medication(s) and the prescribed dosage. Current or past substance abuse? * Known Allergies * Over-the-counter Medications Taken: * History of Psychiatric Hospitalizations or Suicide Attempts: * Reason for Seeking Evaluation At This Time: * Current and Previous Treatment * When & with Whom Any Legal Issues, Court or Disability Cases Pending? * Today's Date * MM DD YYYY Thank you! A staff member will be in touch to follow up.
