New Patient Appointment Request-Modern In Psychiatry

New Patient Appointment Request

Please fill out this form as best you can so we can provide you with the most relevant service and additional information for scheduling.

Are you a new or existing client previously seen at Modern Integrative Psychiatry?

I am a new client

I am an existing client

First name

Last name

Date of Birth

Phone Number

If you are completing this form for a minor, please provide your name and relation

Which Services are you interested in?

Medication Management

Integrative Psychiatry

Medical Cannabis Program Evaluation

Method of payment: Are you planning to self-pay or go through your insurance?

I will use my insurance (accepted only for medication management)

Self-pay

Insurance Company and Plan Name (if applicable)

Member ID (if applicable)

Insurance Policy Holders Name and relation (if different from client)

What are your reasons for our services? Including current symptoms, diagnosis and psychiatric needs (ie.depression/anxiety/ADHD)?

Are you currently having thoughts of hurting yourself or others?

Yes

Do you have a history or current experience with suicide attempts or self-harm behaviors?

Yes

If yes to suicide and self-harm history, please explain

Current & Past Medications & Supplements?

Yes

If yes, list medications (psychiatric and medical), and supplements (including over-the-counter). Include the name/dose/and how often taken

Previous psychiatric medication history (name of medications and year(s) or age(s) when this medication was taken

Have you been hospitalized for mental health purposes (including substance abuse reasons)?

Yes

If yes, explain (name of hospital/year/reason)

Current Drug Use? Illicit/Recreational History? (This includes Marijuana)

Yes

Current Alcohol Use?

Yes

If yes to alcohol and/or drug use- how often and drug and/or alcohol of choice?

What are your goals/expectations of treatment?

Preferred method of contact

Phone

Both

Referred By (Ex.-Therapist, Psychology Today, Google/Internet Search, Friend)

Any additional comments?

Please note that completing this inquiry form does not guarantee an appointment or create a provider-patient relationship. Your inquiry will need to be reviewed to determine if we are a good fit for your needs and the provider's clinical capabilities. We will respond by telephone or e-mail regarding the next steps to schedule your initial appointment.

By checking the box below, I confirm that I am not currently in an emergency situation, I am not suicidal, and I am not a threat to myself or others. I agree to immediately call 911, go to the nearest emergency room, or contact the Suicide & Crisis Lifeline by phone or by sending a text to 988 if I am experiencing a mental health crisis or having thoughts of harming myself or others.

I agree to the terms & conditions