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Patient pre-assessment form

Before we establish care, we ask that you provide information related to your care and consents related to treatment. All information submitted is confidential, secured via HIPAA compliant encryption, and will be used solely for timely onboarding.

To complete this form efficiently, please have the following items readily accessible:

• Patient's ID

• Insurance card(s)

• Method of payment (and cardholder's ID if not the patient)

• Preferred pharmacy address and phone number

The form should take between 5-10 minutes to fill out. We value your time and appreciate you answering all questions completely and truthfully. 

Depending on your needs, we may not always be able to schedule an appointment, but we’ll help connect you with the right level of care.

Patient Information

Name
Date of Birth
Gender
Sex Assigned at Birth
Race / Ethnicity
Race / Ethnicity
Email
Phone
Physical Address
Is your mailing address different from your physical address?
Is your mailing address different from your physical address
A
B
Please upload a copy of the patient's ID or driver's license.
How did you hear about us?
How did you hear about us?
Please provide an emergency contact. This person will be contacted in the event you have a psychiatric emergency.
Phone
Email
Relationship to Patient

Insurance Information

Insurance Provider
Policy/​Member ID Number
Policy Group Number
Policy Holder's Name
Policy Holder's Date of Birth
Patient's Relationship to Policy Holder
Patient's Relationship to Policy Holder
A
B
C
D
Policy Holder's Employer
Upload Patient's Insurance Card (Front)
Upload Patient's Insurance Card (Back)
Do you have Secondary Insurance? 
Do you have Secondary Insurance?
A
B

Preferred Pharmacy Information

In the event medications are prescribed, what is your pharmacy of choice?
Pharmacy Address
Pharmacy Phone Number
Pharmacy Website, if applicable

Appointment Information

Name of Person Completing Questionnaire
Relationship to Patient
Person Completing Questionnaire - Relationship to Patient
A
B
C
Is the patient under the age of 18?
Is the patient under the age of 18?
A
B
Preferred Contact Method
Preferred Contact Method
A
B
C
D
Preferred Phone Number
Preferred Email for Correspondence
Best Time to Contact
Best Time to Contact
A
B
C
Person signing new patient forms will be responsible for the patient and must have the legal authority to consent on the patient’s behalf.

Psychiatric History

Do you currently take benzodiazepines (alprazolam, lorazepam, diazepam)?
Do you currently take benzodiazepines?
A
B
If so, please list the name, dosage (mg), and how often they are taken (daily, twice daily, twice weekly, almost never, etc).
Do you currently take stimulants (Adderall, Vyvanse, Ritalin)?
Do you currently take stimulants (Adderall, Vyvanse, Ritalin)?
A
B
If so please list the name, dose, and frequency. 
How did you hear about us?