Psychiatry Clinic: Appointment Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Westside Free Clinic is now offering Psychiatric Services for evaluating, diagnosing, and treating mental health disorders.

These services are held approximately every two months. Our appointments are available first-come, first-serve. Please refer to our website for our next available Psychiatry Clinic day.

Psychiatric services do not include therapy or counseling services. Please refer to our list of community resources available on our website under "Resources".

Please fill out the following fields:

Name *

What is your date of birth? *

YYYY

What is your phone number (for contacting you about available appointments)? *

What is your preferred email address? *

What are your main concerns that led you to seek psychiatric help? *

Are you seeing or have you been seen by a psychiatrist? *

Yes

Have you ever been diagnosed with a mental health condition before? If yes, please list diagnoses. (If none, please type N/A) *

If applicable, please list your medications.

(If none, please put N/A)

Have you been to Westside Clinic in the past? *

Yes

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms