New Patient Information Form

If you are interested in meeting for the initial intake appointment, please fill out the confidential intake form below. I will then contact you to discuss what brings you in for treatment and how I might be able to help.

Today's Date

YYYY

Name

Please provide the name of the patient

First Name

Last Name

Email Address

Phone

Please provide the most convenient phone number to reach you.

(###)

###

####

Address

Please provide your mailing address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Legal Guardian Name

If patient is under 18 years old, please provide the name of the Legal Guardian

First Name

Last Name

Legal Guardian Name 2

First Name

Last Name

Date of Birth

Please provide the patient's Date of Birth

YYYY

Checkbox

Please check the Gender that most applies to you.

Male

Female

Gender Neutral

Why are you seeking treatment?

Custody Status

If you have sole legal custody, you will be required to provide the appropriate documentation prior to obtaining services

School name and Grade

Substance Use

Is there any history of Substance Use?

Substance Use Description

Please provide a description of the Substance Use.

Medications

Please list any medications that you are taking currently.

Current Treatment Team

Please list your current treatment team, including your current or past therapists, psychiatrists as well as your current primary care physician. This by itself does not grant permission for me to contact them.

Please Note: I am able to provide assessments for most patients seeking care. However, you are not considered a patient of the practice until after you complete the intake. If I determine that you or your child would benefit from a different level of care, I will help you find another facility that can offer the appropriate level of care. Thank you for your understanding.