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Home
About Us
Treatment
Detox
IOP
Medication
Counseling
PHP
Medication Assisted Treatment
Aftercare Program
Services
Alcohol Abuse
Anxiety
Depression
Detox
IOP
Substance Abuse Treatment
OCD
Suboxone
Trauma
Vivitrol
Dual diagnosis
Schizophrenia
Group Therapy
Gambling Disorder
Providers
Resources
Patient Forms
Patient Referral
Holistic Approach
Blog
Contact
Home
About Us
Treatment
Detox
IOP
Medication
Counseling
PHP
Medication Assisted Treatment
Aftercare Program
Services
Alcohol Abuse
Anxiety
Depression
Detox
IOP
Substance Abuse Treatment
OCD
Suboxone
Trauma
Vivitrol
Dual diagnosis
Schizophrenia
Group Therapy
Gambling Disorder
Providers
Resources
Patient Forms
Patient Referral
Holistic Approach
Blog
Contact
Home
About Us
Treatment
Detox
IOP
Medication
Counseling
PHP
Medication Assisted Treatment
Aftercare Program
Services
Alcohol Abuse
Anxiety
Depression
Detox
IOP
Substance Abuse Treatment
OCD
Suboxone
Trauma
Vivitrol
Dual diagnosis
Schizophrenia
Group Therapy
Gambling Disorder
Providers
Resources
Patient Forms
Patient Referral
Holistic Approach
Blog
Contact
Patient Forms
Home > Patient Forms
FILL OUT THE FORM BELOW
Client Name
Please briefly explain your reason for seeking treatment
Are you interested in
Psychiatric Evaluation
Medication Management
Transcranial Magnetic Stimulation (TMS)
Spravato/Ketamine Therapy
Psychotherapy
ADHD Testing or Coaching Services
Genetic screening to inform medication choices
How did you hear about this practice?
Are you currently under the care of a psychiatric provider?
Yes
No
Do you have any prior psychiatric diagnosis?
Yes
No
Are you currently taking any psychiatric medications?
Yes
No
Have you had any psychiatric hospitalizations in the past several years? Please include any residential programs and/or IOPs.
Yes
No
In the past several years, have you had any suicide attempts, self-harm, thoughts of suicide or of harming yourself/others?
Yes
No
Have you had or currently have any substance abuse? Please briefly explain any substance use issues.
Yes
No
Submit
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