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Home
New Patients
Providers
FAQ
Contact
New patients seeking psychiatry
For patients seeking an appointment with a psychiatrist, please complete the form below and we will contact you as soon as possible with available appointments.
Patient's Name
*
First Name
Last Name
Patient's Phone
*
(###)
###
####
Patient's Date of Birth
*
MM
DD
YYYY
Patient's Gender
Female
Male
Other
Insurance Info
*
Referral Source
*
Previous Psychiatric Hospitalizations
*
Include the total number of hospitalizations and the most recent. Type "N/A" if patient has never been hospitalized for a psychiatric condition.
Previous Diagnosis
*
Type "N/A" if no diagnosis has been given.
Current Medications
*
Please list any pain management medications or benzos.
Interest in a Particular Treatment
*
Do you prefer certain medications or types of therapy?
Does the Patient Require Disability/FMLA Paperwork Completed?
*
Please note: Our psychiatrists only complete paperwork for established (3 months) patients.
No
Yes
For Minors Only:
Legal Guardian Name and Relation
*
DHS Involvement
No
Yes
Any Current Legal Issues and/or Custody Disputes?
*
Patient's Street Address
City
State
Zip
Email
Notes
Thank you! We will contact you soon.
