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Prospective Client
We'd like to learn more about what's bringing you to us. The following steps will help us better understand your experiences, goals, and preferences for care.
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* Indicates required question
Patient Name:
*
Your answer
Address
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Email address
*
Your answer
Phone
*
Your answer
What is the main reason you are seeking care?
*
Your answer
Brief Psychiatric History (active diagnosis and medications)
*
Your answer
Treatment type requested:
*
Psychiatric evaluation and diagnosis
Medication Management
Psychotherapy
Other:
Required
What type of Appointment do you prefer?
In-person
Virtual
No preference
Person Submitting the Request
*
Myself
Parents
Other:
Required
How did you find us?
*
Self-referral
Insurance referral
Physician/Therapist referral
Family/friend referral
Other:
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