• New Patient Intake Questionnaire

  • Approximate completion time ~ 15 minutes

    Please fill out this intake form so our clinical and administrative team can begin to assess your treatment protocol.

    We typically respond to this form within 24 hours of receiving it.

    We look forward to supporting you!

  • Your Contact Information

  • Personal Information

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    Pick a Date
  • Pregnancy/Menstruation Info

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    Pick a Date
  • Medical Conditions

  • Surgeries & Anesthesia

  • Allergies

  • Tobacco

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  • Alcohol

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  • Recreational Drugs & Psychedelics

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  • Chronic Pain

  • Primary Care Provider

  • Mental Health Conditions

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  • Mental Health Provider

  • Psychiatric Medications

  • Suicide

  • Addiction Treatment

  • Health Insurance

  • In Case Of Emergency Contact (ICE)

  • Summary Statement

  • Patient Attestation

    By submitting this form, I certify that I have completed this Questionnaire to the best of my ability. I agree to seek immediate help should my symptoms worsen or I experience an increase in suicidal thoughts, feelings or urges.I authorize a representative from CIT Clinics to contact me to discuss treatment options for my condition(s). I also understand that the staff of CIT Clinics may not start and maintain any prescribed treatment regimen if I am not currently under the care of a Mental Health Professional and maintain such care until the completion of my course of treatment. I also consent to receiving emails from CIT Clinics for marketing purposes and I may opt out at anytime in the future by unsubscribing from CIT Clinic's marketing list.
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