Thank you for considering Gray MD Psychiatry as a part of your mental health treatment plan.  
This confidential, encrypted  form allows us to assess whether we can provide you with the high quality psychiatric care we strive to give every patient.
Please answer the following questions to the best of your ability, memory and knowledge.
After submitting the form, we will contact you with either further information on how to schedule an appointment or a referral list of treatment providers who are more appropriate for your treatment needs.

Submitting this form does not represent a doctor- patient relationship.
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By checking Yes, you acknowledge and understand the following:                          Completing this form does not imply or establish a physician- patient relationship. All responses are confidential.
By checking Yes, you acknowledge that you are not currently suicidal. If you are suicidal, please call 911 or go to your nearest emergency room. We do not provide emergency services at this practice. *
By checking yes, you acknowledge and understand the following: WE DO NOT ACCEPT ANY INSURANCE and we are considered an out of network or cash pay practice. If you plan to seek reimbursement from your insurance company, we will provide a detailed receipt. We do accept HSA (health savings account) cards or FSA (flexible spending account) cards. You are fully responsible for financial costs, please see the clinical services and fees page on our website for more details. *
Last Name *
Phone number *
Email Address *
We will respond to you via this email address and above phone number. If neither is confidential, please provide an alternative contact option.
Date of Birth *
What is your preferred pronoun? (eg. He, her, they, etc.)
What are your current symptoms or psychiatric needs? (Select all currently present) *
Although we have extensive experience treating a wide array of mental health conditions, we are currently unable to accept patients with ACTIVE/ CURRENT psychosis, substance abuse, mania, self harm behaviors or violence.
Any current usage of illegal drugs, including marijuana? *
What drugs are you using and how often?
Are you seeking medication treatment, psychotherapy, both or unsure? *
Date and Reason for most recent hospitalization (within last year). Write none, if this does not apply. *
 Number of past psychiatric hospitalizations *
What are your personal goals for treatment? *
Please share any other information you would like us to know about you or past experiences with psychiatric medications, therapy, psychiatrists or therapists.
Thank you for completing this questionnaire. You may now click the following link to schedule a call with the clinical coordinator who will complete your intake, registration and scheduling.
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