New Patient Inquiry Form


We are accepting new patients on a case-by-case basis and request the following information to make sure we are a good fit for your needs. Please take the time to provide detailed responses in this form.


Upon receipt of this information, we will get back to you within 3 business days via email. If you are in crisis, please call 911 or the crisis line: 988.


Filling out this form does not guarantee an appointment with one of our providers.

Demographics

Are you inquiring on behalf of the patient?*

Please include your name, email address, phone number, and relationship to the patient.

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What is your/the patient's birth sex?
Phone

Please note: We are not in-network with all carriers listed. If you select an out-of-network carrier, we will let you know once we review your inquiry.

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Drag and drop files here or

Mental Health History

Are you/the patient currently experiencing suicidal ideation (thoughts to end your life)?*

If you are in crisis, please call the crisis line at 9-8-8.


If you need immediate care, please call 9-1-1.

Have you/the patient ever attempted to end your/their life?*
Do you/the patient have a history of mental health and/or psychiatric treatment?*
Have you/the patient ever been hospitalized for a mental health issue?*

Such as: inpatient admission, emergency room visits, partial hospitalization programs (PHP), intensive outpatient programs (IOP)

Include: duration of stay, hospital, reason for admission

Are you/the patient currently seeing any other provider(s) for mental health issues?*

Therapists, nutritionists, psychiatrists, nurse practitioners, PCP's, etc

Medical History

Are you/is the patient taking any medications?*
Have you/the patient ever experienced a brain injury?*
Have you/the patient ever experienced a seizure?*

Please specify frequency.

Have you/the patient ever welded or worked with metal fabrication?*

Such as manufacturing, machinist, jeweler, or similar.

Do you/the patient have any conductive, ferromagnetic or other magnetic-sensitive metals implanted in your/their head?*

Examples include cochlear implants, implanted electrodes/stimulators, aneurysm clips or coils, stents, and bullet fragments.

Do you/the patient have any body implants?*

Examples include pace makers, vagus nerve stimulators, implantable cardioverter defibrillators, etc.

Do you/the patient have any neck, facial, or head tattoos done with metallic or magnetic-sensitive ink?*

Heavy metals are often present in colored inks. Vegan and/or organic tattoo ink does not typically contain metals.

Referral

We would love to send them our thanks!

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