Psychiatric Clinic Patient Enrollment (16+)

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AssalamuAlaykum,

This is the enrollment application for the Al Shifa Psychiatric Clinic. We are now taking new patients.

Please note we are only accepting patients that are aged 16+

This psychiatric clinic offers free screenings, assessments, and evaluations for addictions, ADHD, anxiety, depression, addictions, and more.

*** Once you fill out the form, we will reach out to you for scheduling and next steps ***

We aim to keep your information as confidential as possible inshaAllah. We will ensure that access to your information will be kept limited to the necessary staff and the physicians.

If you have any questions at all, please do not hesitate to reach out to clinic@islamiccentermn.org or visit alshifamn.org.

Email *

Flyer

Patient First Name *

Patient Middle Name

Patient Last Name *

Patient Date of Birth (we only accept patients 16+) *

YYYY

Patient Sex/Gender *

Male

Female

Other:

Ethnicity

Home Address *

Home City *

Home State *

Home Zip Code *

Phone Number *

Email Address *

How were you referred to us or how did you hear about us? *

What is the primary reason for wanting to be seen? *

Anger

Attentional Difficulties

Behavioral Problems

Depression

Educational Difficulties

Anxiety

Autism Spectrum Concerns

Defiance/Oppositionality

Eating/Body Image Issues

Moodiness

Other:

Select all of the following that are applicable *

In therapy now

In therapy in the past

In the hospital now or recently

Hospitalized for psychiatric reasons in the past

On psychiatric medication now

Taken psychiatric medication in the past

Currently having active suicidal thoughts, such as planning or making preparations to attempt suicide?

Currently engaging in self harm behavior, such as cutting, burning, etc

Attempted suicide in the past

Known neurological or genetic disorder

None of the above

Required

What kind of care is being sought? *

Medication

Psychotherapy

Both

Not sure

Other:

Please describe any relevant past medical history, including existing diagnoses. *

What psychiatric medications are you currently taking, and at what dose and frequency? *

Please explain why you would like to be seen at the Shifa Psychiatric Clinic *

A copy of your responses will be emailed to the address you provided.

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