New Patient Screening

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

Primary Insurance Subscriber Birthdate

Primary Insurance ID

Secondary Insurance Provider

Secondary Insurance Subscriber

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?