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New Patient Inquiry
To submit a new patient inquiry, please complete the below form. Dr. Hughes will follow up as soon as possible.
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* Indicates required question
This request is not an emergency or urgent matter - I wish to proceed
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Yes
How were you referred to me?
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Your answer
First Name
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Your answer
Last Name
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Email
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Your answer
Phone number
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This will be used to follow up on your inquiry.
Your answer
Is it OK to leave a message at the above number?
*
Yes
No
Is it OK send SMS text messages to the above number? (Standard SMS fees may apply)
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Yes
No
Gender
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Female
Male
Other:
Please indicate any preferred pronouns
Your answer
In your own words, what is your goal for treatment?
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Your answer
Are you currently using any illicit substances (such as ecstasy, methamphetamines, cocaine, etc) or struggling with daily use of marijuana or alcohol? If yes, please explain
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Yes (Please provide more detail below)
No
(If yes to the above) Please provide more detail
Your answer
What are the primary areas you would like to focus on? (Select all that apply)
Alcohol Abuse
Anger
Anxiety
Attentional Difficulties
Autism Spectrum Concerns
Bipolar Disorder
Behavioral Problems
Depression
Drug Abuse
Irritability
Nutrition & Mental Health
Psychosis and or Schizophrenia
Other:
Current Insurance Company
*
Choose
I don't plan to use insurance (Cash Pay)
Aetna
Blue Cross Blue Shield
MODA
Pacific Source
Please indicate the types of psychiatric care that you are interested in (Select all that apply)
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Medication
Psychotherapy
Not sure
Other
Required
Check all of the following that are applicable
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I am currently in psychotherapy
I have received psychotherapy in the past (But not currently)
I am currently on psychiatric medication
I have taken psychiatric medication in the past (But not currently)
None of the above
Required
What medications are you currently taking? Please provide names and doses, including both psychiatric and non-psychiatric meds.
Your answer
Do you have any allergies to medications? If yes - please explain.
Your answer
Do you have a history of self harm or violence towards others? If yes, please explain.
*
Your answer
Do you currently have any legal issues? If yes, please explain.
Your answer
Do you have any chronic medical conditions? (e.g. Diabetes, heart disease, seizures?) If yes, please explain.
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Your answer
Does anyone in your immediate family struggle with mental illness? If yes, please explain.
Your answer
I have been hospitalized for psychiatric reasons in the past
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Yes
No
If you have one - who is your current primary care provider? (Family Doctor)
Your answer
I have attempted suicide in the past
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Yes
No
Are there any times that would NOT work for scheduling an appointment
Your answer
Do you have any other scheduling limitations?
Your answer
I understand the following: If I do not have one of the insurance providers accepted by Dr. Hughes, I am responsible for payment in full at the time service is rendered, unless other arrangements have been made. I will be provided a statement so I may try to get some reimbursement from my insurance company if I am eligible.
*
Yes
No
I understand that Dr. Hughes will reply to this message as soon as possible, and that this request for an appointment does not establish a doctor/patient relationship.
*
Yes
No
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