Hadi Farah, MD, LLC - Initial Questionnaire
Thank you for visiting my website. Filling this questionnaire is the first step to know if you will be better helped in my clinic or in the care of other professionals.

Although this is a confidential form, feel free to fill it anonymously if you wish.

Please be advised that filling this form does not create a patient-doctor relationship in my clinic.

If this is an emergency, please do not complete this questionnaire. Instead, please call 911 or your county crisis hot line.
Identifying Information
Please tell us some basic information about you: age, identified gender, and spoken language.
In which state do you live? *
The main issue *
In a few lines, please tell us briefly about the main issue you are seeking help for.
History
Please check all what applies (current or past.)
History Details (optional)
This is an area where you can provide more details regarding your answer to the question above if you wish.
Current Medications *
Please list all psychiatric medications you are taking regularly (please include the dose if you know it.)
Is there a specific question that you'd like to get an answer for?
I'm interested in: *
Required
More Details (optional)
This is an area where you can provide more details regarding your answer to the question above if you wish.
Are you OK with online visits (video calls) instead of in-person visits? *
How often would you like to meet? What does your schedule look like?
Will you be using insurance to pay clinic fees? Which insurance do you have?
How did you hear about this clinic?
Which email address should we use to reach you? *
By providing your email address, you are hereby giving your consent for a response by email, understanding that email may not be encrypted and even if encrypted, email poses security risks that threaten confidentiality (i.e., other people reading your messages, hacking and email pirating, lost or stolen devices.) If you would prefer a response in another format, please indicate your preference.
Name or initials (optional)
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Hadi Farah, MD, LLC. Report Abuse