New Patient Intake Information Form

New Patient Intake Information Form

If you would like to become a new patient of HaganHealth, please fill out the form below.
Name *

First Name Last Name
Email *
example@example.com
Date of Birth: *

Month Day Year
Date
Sex:

Male Female
Phone Number: *
Which insurance company do you have? *
How did you hear about us?
Would you like psychiatry, counseling, or both? *
What would you like to be seen for? *

ADHD Anxiety Depression Bipolar Disorder Eating Disorder Sleep Disorder Post Traumatic Stress Disorder Other
If " Other ", please specify:
Have you seen a psychiatrist in the past? If so, who? *
Are you currently taking ANY prescription medication? *
Are you currently in pain management? If so, what is your treatment/medication? *
Have you been hospitalized in the past three month due to mental health reasons? *

Yes No
If " Yes ", then when and where were you hospitalized?
Are you taking Suboxone, Methadone, or similar medication? *

Suboxone (Subutex, Zubsolv) Methadone Vivitrol Injection Other None
Insurance Information: *
Policy Holder:
Policy Holder DOB:
Member ID:
Group number:
Address, if different than the patient:

Should be Empty: