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Please fill out this form to be considered for an appointment
Name
Date Of Birth
Email
Mobile Number
Mailing Address
By submitting your phone number and email, you agree to receive messages about your appointment and health communications
Marital Status
single
Married
Divorced
Separated
Other
Employment
Student
Employed (full time)
Employed (Part Time)
Self Employed
Current medical condition
Reason for Seeking Services and/or Current Psychiatric Condition
Are you taking any medications?
Yes
No
If yes, please list the medications you are taking as well as supplements. Include dosages.
Are you pregnant
Yes
No
If Yes, How many weeks?
Have you been recently hospitalized in the past 6 months?
Yes
No
If Yes, please indicate the reason for your hospitalization and length of stay
Do you drink alcohol?
Yes
No
If yes, how much do you drink a day/week
Do you smoke?
Yes
No
If yes how many cigarettes do you take in a day/week?
Do you use any substances?
Yes
No
If yes, please name what you use:
Have you been arrested in the 1 year?
Yes
No
If yes, what was the reason for your arrest?
Do you have thoughts of suicide:
( If yes, please stop filling this form and call the National Suicide Prevent line at 1-800-273-8255)
Yes
No
Credit Card information
Self pay- Initial visit
Follow up visit
Co-pay
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