New Patient Inquiry Form
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Name of Patient: *
Age and Date of Birth: *
Contact / Mobile Number (or if child, list BOTH parents' phone numbers): *
Email: *
Reason(s) for Seeking Appointment at ResWell:
Current Medical Problems (ex: diabetes, asthma, heart problems):
Current Medications:
Prior Medications (name of medication, dates used, reason for stopping):
Prior Psychiatric Hospitalizations:
Substance Use (current or past: marijuana, alcohol, etc):
Any Legal / Custody Issues:
Therapist Name and Phone Number (past or current):
Psychiatrist Name and Phone Number (past or current):
Preferred ResWell Provider:

How Did You Hear About ResWell (include name and email address of referring provider if applicable)?
Disclaimer: Completing this inquiry form does not establish you as a new patient of ResWell. Our intake coordinator will contact you upon receipt of the completed form. If you have any urgent/emergent or safety concerns, like suicidal thoughts, please call 988 or go to the nearest ER.
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