New Client Information & Areas of Concern
Please fill out this form as best you can so we can provide you with the most relevant service.
First name
Last name
Email
Phone Number
Date of Birth
Which medications are you currently on ?
Previously prescribed medications
Current Mental Health Challenge(s)
ADHD (Attention-Deficit/Hyperactivity Disorder)
Anxiety Disorders
Bipolar Disorder
Borderline Personality Disorder (BPD)
Depression
Eating Disorders (e.g., Anorexia, Bulimia)
Obsessive-Compulsive Disorder (OCD)
Panic Disorder
Post-Traumatic Stress Disorder (PTSD)
Schizophrenia
Substance Use Disorders
Reason for Visit: Choose 1 or more
Evaluation & Diagnosis
Continue previously prescribed medications
Find the right medications for symptom relief
Receive new prescriptions
Talk Therapy
Method of Payment
Insurance
Self-Pay
Current Insurance Company if Applicable
Requested Dates of Appointment
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