New Patient Screening Form

Thanks for your interest in you or your child becoming a new patient. Please fill out our secure new patient form so that Dr. George can determine how best we can help. If you are currently actively suicidal, please call 911 or Colorado crisis line (844-493-8255) or go to your nearest emergency room.

Contact Name

Contact Email

Contact Phone Number

How did you hear about us?

Patient Name

Patient Date of Birth

Patient Address

Primary Insurance Provider

Primary Insurance Subscriber

Whose insurance is this?

Primary Insurance Subscriber Birthdate

Primary Insurance ID

Secondary Insurance Provider

Secondary Insurance Subscriber

(Whose insurance is this?)

Secondary Insurance Subscriber Birthdate

Secondary Insurance ID

Briefly describe what issue(s) are leading the patient to seek treatment, including any prior diagnoses.

When did you first notice the problem(s) begin?

What effects have these problem(s) had on the patient’s functioning (at home, school, work, or with friends)?

Has the patient seen a psychiatrist and/or therapist in the past? If so, whom and when was the last visit?

Has the patient ever been hospitalized psychiatrically? If so, how often and why?

Is the patient currently on psychiatric medications or medical marijuana? If so, list medication names and doses.

Has the patient been on psychiatric medications previously? If so, please list medications.

Does the patient have any past or current issues with addiction or substance abuse (e.g. drugs, marijuana, nicotine, pornography, video games)? If so, please list.

Does the patient have any self harm behaviors (e.g. cutting, suicide attempts)? Please briefly describe.

What would be your goal for treatment?

Time's up

New Patient Screening Form

Brighter Day Psychiatry TMS Clinic | Rose George MD