Compassionate, full-spectrum psychiatric and mental health care.

Patient Identity

Patient First Name *

Patient Middle Initial

Patient Last Name

Patient DOB *

Gender *

Email *

Home Phone *

Cell Phone *

Mailing Address *

Appointment

Preferred Office Location *

Service *

Clinical History

This section is confidential and is used only to help your provider prepare for your first visit.

Please select the appropriate box, if you have ever been diagnosed or experienced any of the following

PsychosisSchizophreniaDelusional disorderBorderline personality disorderDementiaCognitive ImpairmentMemory IssuesEating disorders (Anorexia, Bulimia)AutismAspergerAnxiety/PanicDepressionManiaInsomniaMood Swingsirritability/Anger IssuesImpulsivityADHD/ADDBipolar Disorder (I or II)NONE OF THE ABOVE

Have you had any suicidal thoughts or ideations in the past 7 days? *

YesNo

If you are having thoughts of suicide, help is available right now.

Call or text 988 to reach the Suicide & Crisis Lifeline, available 24/7. If this is an emergency, call 911. You can also call our Sarasota, FL office at 941.677.3366.

Do you drink any alcohol or use any other substances? *

YesNo

Do you have any substance use or abuse issues? *

YesNo

Do you need us to prescribe medication? *

YesNo

Preferred Pharmacy

Preferred Pharmacy Phone Number

Preferred Pharmacy Address

Are you currently on any PSYCHIATRIC medication? *

YesNo

Have you recently been discharged from an inpatient facility? *

YesNo

Have you ever seen a psychiatrist? *

YesNo

Have you ever seen a therapist? *

YesNo

Legal / Administrative

Do any of the following apply to you: *

Pending legal issuesProbationAttorney may be requesting medical recordsNONE OF THE ABOVE

Is this evaluation requested or mandated by court / school / work / other? *

YesNo

Are you planning on applying for short-term or long-term disability? *

YesNo

Insurance

Please bring your insurance card(s) with you to your appointment — we no longer collect card images through this form.

Primary Insurance

Primary Insurance *

ID# *

Provider Services Phone Number *

Address for claims *

Insured Subscriber's Name (if other than patient's)

DOB (if other than patient's)

Secondary Insurance (optional)

Secondary Insurance

ID#

Provider Services Phone Number

Address for claims

Closing

How did you hear about us?

FORM FILLED OUT BY *

Additional information you would like to share with us

All patients 18+ years old must consent to this request. *I consent to this request.

Cancellation *We require 2 business days of advance notice to cancel or reschedule appointments, otherwise a cancellation fee will be charged. By checking the box, I agree.

Consent *By providing a telephone number and submitting the form, you are consenting to be contacted by SMS text message and agreeing to our Privacy Policy. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information.

YOUR DIGITAL SIGNATURE *

Type your full legal name.

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