New Patient Intake Information Form
If you would like to become a new patient of HaganHealth, please fill out the form below.
Date of Birth:
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?
Post Traumatic Stress Disorder
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?
If " Yes ", then when and where were you hospitalized?
Are you taking Suboxone, Methadone, or similar medication?
Suboxone (Subutex, Zubsolv)
Policy Holder: Policy Holder DOB: Member ID: Group number: Address, if different than the patient:
Should be Empty: