Please answer the following questions. Your answers will assist us in assessing how we may address your needs.

1. Please provide the following information about the person who will be receiving services.

Patient's Name

E-mail:
Password: (5 or more Characters)
Confirm Password:

Mailing Address


2. Please describe in your own terms why you are seeking psychiatric services. Please do not include any diagnosis.


3. Please provide the reason and the outcome of any current or previous psychological, mental health, and psychiatric treatment(s) you have received. Please include any psychiatric hospitalizations and/or psychological evaluations and also provide the dates of your services. You can include any diagnosis assigned to your condition here.


4. Please list all medications that you are taking and what you are taking them for. Please include the dose and frequency of each medication. Please also include a list of any vitamin, herbal supplements and/or over-the-counter medications that you are also taking and what you are taking them for.


5. How will you be paying for services?


Please provide your Primary Insurance carrier and plan.

If have a Secondary Insurance Plan, please provide the carrier and plan.

6. Who is your Primary Care Physician (PCP)?


Please check this box if we have your permission to contact your PCP or referral source.
Contact Information

7. Please provide your referral source:

If Other, please explain.

8. Is your evaluation needed for a 3rd party?

If yes, please explain.

9. Please provide any additional information that you think would be helpful in assessing your needs. Also, please provide the expectations of your service.