New Patient Questionnaire
Office of Andrew Cole, CRNP-PMH

If you are a potential new patient interested in getting scheduled, please fill out and submit this form. Patients are expected to attend monthly follow-up appointments (at minimum) if both patient and provider decide to move forward after the initial intake appointment.

All appointments are held via telemedicine. Office and appointment hours are 10 AM to 5 PM on Tuesdays, Wednesdays, and occasionally Thursdays. The provider sees adult patients only, ages 20 to 65. Thank you.
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Email *
Your response to this questionnaire is used to aid the provider in determining whether or not the services he offers are a good fit for you and whether or not he can meet your needs. The completion of this questionnaire does not establish a provider-patient relationship. Please make plans to pursue care with another provider if you do not receive a response from this office within 5 business days of submitting this questionnaire. *
All appointments are held exclusively via telemedicine. In-person appointments are not offered. The initial appointment consists of a thorough history, and it lasts between 60 and 120 minutes. A blood pressure cuff is required at home for your first appointment in order to measure your vital signs. Follow-up appointments last between 20 and 30 minutes, occasionally longer, and patients are expected to schedule a follow-up appointment at least every 4 weeks. Office and appointment hours are 10 AM to 5 PM on Tuesdays, Wednesdays, and occasionally Thursdays. *
Due to current telemedicine laws, you will need to be located within the state of Maryland or West Virginia for all appointments. Are you a MD or WV resident or residing in the state of MD or WV? *
The provider sees patients between the age of 20 and 65.  Are you between the age of 20 and 65? *
If you are completing this questionnaire for someone else, please direct them to complete this questionnaire themselves. The office will not respond to questionnaires completed by anyone other than the potential new patient. Are you filling this questionnaire out for someone else? *
Are you currently prescribed benzodiazepines or Z-drugs (e.g. Xanax, Klonopin, Ativan, Valium, Ambien, etc.) or psychostimulants (Adderall, Ritalin, Concerta, Vyvanse, etc)? These medications will not be prescribed by this practice to new patients due to changing telemedicine regulations. *
What services are you seeking? *
Required
Full Name *
Date of Birth *
Street Address *
Phone Number *
Insurance Provider (If any part of your insurance is through Medicare, then this provider is unable to see you) *
Insurance Member ID Number (found on your insurance card) *
Please explain in detail why you are seeking help. *
Past or Current Psychiatric Diagnosis *
Required
Current Psychiatric Medications and Dosages *
All Other Current Medications and Dosages (Eg: Medications for pain, sleep, or medical conditions) *
Do you have any history of inpatient psychiatric hospitalization? *
Current Psychiatrist or Psychiatric Nurse Practitioner *
Current Therapist *
Are you currently struggling with alcohol use or substance use (including marijuana)? *
If you answered "yes" to struggling with alcohol use or substance use (including marijuana), please explain in detail your struggles. Otherwise, simply respond "No." *
Are you currently struggling with self-injury behaviors? (Eg: cutting, scratching, burning, self-hitting) *
Do you have any history of trauma or abuse? *
Are you pregnant, breastfeeding, or planning to become pregnant in the next 12 months? *
Are you seeking a diagnosis with the intention of applying for Disability or Leave? *
Do you want to incorporate your Catholic or Christian faith into services offered by this provider? *
How did you find us? *
If you were referred by a provider or a therapist, please share who you were referred by. *
Preferred Method of Contact for Scheduling *
Required
By submitting your response to this questionnaire, you consent to communication via phone, email, or text message. You also consent to the review of your medication records contained in the Prescription Drug Monitoring Program. Your typed named below will be considered a signature acknowledging your understanding of these terms. *
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