Shepherd's Gate New Patient Questionnaire 
We are so happy you're here! If you would like to schedule an appointment for medication management, please answer the following questions. A staff member will be in contact with you as soon as possible. 

Note: these answers are only visible to staff members, and they are used solely for the purpose of contacting the client, verifying insurance benefits, and creating a patient chart for appointments. 
If you are experiencing an emergency or mental health crisis, please call 911, 988, or go to the nearest emergency department. 
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Person filling out this form *
Please enter the client's full legal name and date of birth *
Client's mailing address  *
Contact phone number and email address *
Name of insurance company 
Note: we do not accept Medicare, Medicaid, or TennCare at this time. Please enter 'self-pay' if you are not insured or will be paying out-of-pocket for appointments.  *
Current psychiatric medications 
Please enter 'none' if no current prescribed medication
 *
Please list all past psychiatric hospitalizations
Enter 'none' if not applicable 
 *
Please select one of the following:  *
Brief description of why you are seeking care/goals for treatment *
How did you hear about us?  *
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