MindSpa Psychiatry - New Patient Intake Form

Let's start with your name

What is your email address

What is your phone number

What is your date of birth

Gender
—Please choose an option—MaleFemalePerfer not to say

Insurance

ID Number

Reason (optional)
—Please choose an option—DepressionAnxietyPTSDOCDADHDInsomniaOther

How did you hear about us?(optional)

Have you seen a psych provider before?
—Please choose an option—YesNo

Do you have a therapist?
—Please choose an option—YesNo

Past Psychiatric Diagnosis?

Any Sub/Alch Abuse History?
—Please choose an option—YesNo

Sober time and D.O.C.

Any Recent Psych Hospitalizations?
—Please choose an option—YesNo

Any Current Suicidal thoughts?
—Please choose an option—YesNo

Current Psychiatric Medications?

Any other medical medications?

Any Medical Conditions?

Neuro (History of Seizures)?

Any Allergies to Food or Medications?

Current Pharmacy Address?

Height

Weight

I have read and agreed to the Privacy Policy and Terms of Use, and I confirm that I am at least 18 years old and have the authority to make this appointment.
I accept
I don't accept

I agree to receive text messages from this practice and understand that message frequency and data rates may apply.
I accept
I don't accept