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Dr. Gajiev - New Patient Inquiry

Hello and thank you for your interest in our psychiatric practice. To best assess the appropriateness and fit of our services for your needs, please answer the following questions as honestly as you can. Please note that your responses are confidential.

What is your full name?

What is your date of birth?

What is the best phone number to contact you?

What is the best email address to contact you?

Is this your first time seeking psychiatric services?

Is this your first time seeking psychiatric services?
A
B

Do you intend to use your health insurance to cover treatment?

In a few sentences, what are you seeking to address in treatment?

If known, please list any previous and present diagnoses here:

Do you currently take any medications?

Do you currently take any medications?
A
B

Are you currently struggling with substance use?

Are you currently struggling with substance use?
A
B

Do you have a history of inpatient psychiatric treatment?

Do you have a history of inpatient psychiatric treatment?
A
B

Are you seeking treatment related to any of the following:

Are you seeking treatment related to any of the following:

Are you aware that our psychiatric services take place primarily online and are you willing to engage in telemedicine (virtual) sessions?

Are you aware that our psychiatric services take place primarily online and are you willing to engage in telemedicine (virtual) sessions?
A
B

How did you find out about our practice?