Intake Form
Please fill out this intake to the best of your ability. Thank you.
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First Name *
Last Name *
Date of Birth *
Preferred Pronouns
Address/Street *
Apartment/Suite
City *
State *
ZIP *
Home Phone
Mobile Phone *
Work Phone
Medical Insurance *
Referred By (Please specify: Google, Facebook, Twitter, Instagram, etc.) *
Primary Care Physician
Reason for Appointment *
Psychiatric/Medical History *
Current Medications (Medical and Psychiatric)
Are you currently seeing a therapist? *
History of Hospitalizations *
Medication History
History of Violence and Suicidal Attempts *
History of Drug/Alcohol Dependence and Methadone Maintenance *
History of Addiction Treatment *
Legal History
Current Employer *
E-Mail Address *
Questions for M.D.
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