New Patient Questionnaire

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Name

E-mail address *

Telephone number (if you would like me to call you). Please make sure this is a number where it is acceptable to leave a message if you are not available

What problems are you wanting to address? *

Have you been treated by a psychiatrist or other mental health professional (psychologist, counselor, etc) in the past year? *

Yes

Please list all medications, including doses, that you currently take:

Are you a Medicare recipient? *

Yes

Are you a Medicaid recipient? *

Yes

I am aware that Dr. Handley is not an in-network provider for any insurance company. While I may be eligible for reimbursement for out-of-network care I will need to contact my insurance company for these details. Additional information can be found here: http://www.davidhandleymd.com/newpatient/ *

I acknowledge the above

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