New patient – Relief Healing Mental Health Services

Are you an existing patient Click here

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

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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