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Email(Required)

Date of Birth

Insurance Name

Insurance ID Number

Insurance Group Number (N/A if not applicable)

Insurance Policy Holder (Include Name, date of birth, Address) - N/A if you are the policy holder

Who referred you/ how did you hear about us?

What is your goal for seeking treatment ?

Please List any mental health diagnoses (previous or current)

Please list current mental health medications (include name, dosage, frequency)

Any current (or past) thoughts of harming yourself ?

If yes, date of last suicide attempt

Any previous psychiatric hospitalizations ? (If Yes, last hospitalization date)

Please list any alcohol or substance use (N/A if not applicable)