Name

First Name

Last Name

Reason for seeking treatment...

Date of Birth

YYYY

Please list your diagnosis (if known) and your current medications

Describe any ongoing medical conditions

What is your health insurance plan?

Phone

(###)

###

####

Who is your preferred provider?

(please note that choosing a provider does not guarantee that they are taking new clients)

Who is your current psychiatric prescriber? Why are you looking for a change in providers at this time?

If not applicable, please write N/A

What are your main concerns/goals for psychiatric treatment?