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Pre-screening Form
Contact info
*
Email address
*
Phone number
*
Preferred contact method
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Preferred contact method
Phone
Email
Best time to reach you
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What brings you in?
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What brings you in?
A
Alcohol use
B
Opioid use
C
Other substance use
D
ADHD
E
Anxiety
F
Mood disorder
G
Medication management
H
Other psychiatry
Are you currently using substances:
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Are you currently using substances:
A
Yes
B
No
C
Prefer not to say
Have you been in treatment before
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Are you currently experiencing a crisis or safety concern?
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Are you seeking inperson, telehealth or either?
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How did you hear about Dr. Singh? (psychology today, google, referral, other)
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I understand this form is for scheduling purposes only and does not establish a patient-provider relationship
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I understand this form is for scheduling purposes only and does not establish a patient-provider relationship
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