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Consultation Request
Please fill out this form if you are interested in starting treatment at Forte Psychiatry. The information provided in this form is used for non-emergent patient consultation requests only - if you have an emergency, please close this page and call 911 immediately. The information will be reviewed by Dr. Medeiros and you will be contacted within 1-2 business days via email or phone. 
Email *
Full name *
Date of birth (mm/dd/yyyy) *
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E-mail *
Phone number *
Gender Identity *
Required
What is the reason you are seeking mental health care? Please provide a brief description. *
Have you been diagnosed with psychiatric conditions previously? Please describe. *
Are you currently on psychiatric medications? If so, which ones? *
Do you have a history of suicide attempts or self-injurious behaviors? If so, please describe further including the most recent. *
Do you have a history of or currently struggle with substance use issues (alcohol, cannabis, etc)? *
Have you ever been hospitalized due to psychiatric issues? *
Have you ever struggled with psychotic symptoms (hallucinations, delusions, etc)? *
How did you find Forte Psychiatry? *
Preferred contact method *
Required
Please feel free to add any additional information you think is relevant.
By submitting this form through this online portal, you understand and agree that transmitting health information by unencrypted email or electronic messaging carries certain security risks, and you choose to proceed despite those risks. Such risks may include the possibility that unintended or unauthorized parties could access the protected health information you provide in this form. By selecting “Yes, I agree to submitting this form and acknowledge the risks," you consent to release Forte Psychiatry and Dr. Carolina Medeiros from responsibility for any unauthorized access, use, or disclosure of your protected health information that may occur as a result of electronic transmission. *
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