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What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

What kind of care is being sought?

Psychotherapy Medication Other Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

What brings you to psychiatric care at this time?

How long have you been experiencing these concerns?

Are these symptoms currently interfering with your work, school, relationships, or daily functioning?

Not at all Somewhat Significantly Severely

Are you currently seeing a psychiatrist, psychiatric nurse practitioner, therapist, counselor, or other behavioral-health provider?

If yes: Who and for what type of treatment?

Are you currently taking any psychiatric medications?

If yes: Please list the medication(s), dose(s), and prescribing provider if known.

Have you previously taken psychiatric medications? If yes: Which medications were helpful or caused significant side effects?

Have you ever been diagnosed with a mental-health condition?

If yes: Please list any diagnoses you have been given.

Are you specifically seeking a prescription or continuation of a controlled medication?

Examples may include stimulants such as Adderall/Vyvanse or benzodiazepines such as Xanax/Klonopin/Ativan, and other controlled substances.

Do you have any significant medical conditions that may affect psychiatric treatment?

If yes: Please briefly describe.

Are you currently pregnant, trying to become pregnant, or breastfeeding?

Do you have a primary-care provider?

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