New Patient Interest

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Internal CommentsHidden on patient form, can be used in table view.
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I am completing this form for:* This field is required.
Myself
My Child
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What is your name?* This field is required.Enter YOUR first and last name. If this is for your child, we will ask for their name too.
First Name
Last Name
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Now
Date
Month
Day
Year
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Submitter's Date of Birth (Self/Parent, or Guardian)* This field is required.MM/DD/YYYY
Date
Month
Day
Year
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Filler Age
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What is the preferred language for discussing healthcare?* This field is required.
Please Select
English
Spanish
Arabic
Burmese
Chinese—Cantonese
Chinese—Mandarin
French
Hmong
Korean
Marshallese
Persian (Farsi)
Russian
Vietnamese
Zomi
American Sign Language (ASL)
Other—please specify
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Does the patient need an interpreter to communicate with the care team?* This field is required.
Yes
No
I am not sure, please contact me
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Which language does the patient need translation for?* This field is required.
Please Select
English
Spanish
Arabic
Burmese
Chinese—Cantonese
Chinese—Mandarin
French
Hmong
Korean
Marshallese
Persian (Farsi)
Russian
Vietnamese
Zomi
American Sign Language (ASL)
Other—please specify
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Other Language * This field is required.
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Mailing Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Cell Phone Number* This field is required.
Please enter a valid phone number.
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Home Phone Number* This field is required.
Please enter a valid phone number.
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Email* This field is required.
example@example.com
Confirm Email
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Your Biological Sex (Self/Parent/Guardian)* This field is required.If this is for your child, we will ask for their info next.
Male
Female
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Child's Name* This field is required.
First Name
Last Name
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Child's Date of Birth* This field is required.
Enter Date (MM), Day (DD), and Year (YYYY)
Month
Day
Year
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Age of Child
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Child's Biological Sex* This field is required.Sex on birth certificate
Male
Female
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We are in network with the plans below. Please select the one you will be using.* This field is required.
BlueCross BlueShield
CommunityCare
EDS HealthChoice
UnitedHealthcare
Self-pay
OK Medicaid (18 and under only)
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Insurance ID* This field is required.
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Insurance Group Number* This field is required.
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Insurance Subscriber* This field is required.Who is the policy registered to?
I am the subscriber
My child is the subscriber
Someone else is the subscriber
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Insurance Subscriber's Name* This field is required.
First Name
Last Name
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Insurance Subscriber's Date of Birth* This field is required.
Date
Month
Day
Year
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Relationship to Subscriber
Parent
Guardian
Spouse
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Does patient have secondary insurance coverage?* This field is required.We will collect this info before scheduling.
YESNO
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For what reason (s) are you requesting treatment?* This field is required.
ADD/ADHD
Anxiety
Autism
Bipolar Disorder
Depression
Insomnia
Personality Disorder
Panic Attacks
OCD
PTSD
Other
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Were you referred for Spravato® Treatment?* This field is required.
YESNO
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Has there been a previous diagnosis of ADD or ADHD?* This field is required.
YESNO
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Has ADD/ADHD testing been completed?* This field is required.
YESNO
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Age when ADD/ADHD testing was completed* This field is required.
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Who performed the ADD/ADHD testing* This field is required.
Clinical Psychologist
Pediatrician
Primary Care Provider
Psychiatrist
Other
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Is there a history of OUTPATIENT mental health care?* This field is required.Eg: Psychiatrist, therapist, psychologist
Yes
No
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Enter Facility Name(s), dates (approximate is ok), and reason for discontinuation.* This field is required.
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Has there been a previous diagnosis of a psychiatric illness?* This field is required.
Yes
No
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Please list previous psychiatric diagnoses* This field is required.Enter NA if this does not apply to you.
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Has a personality disorder been diagnosed ?* This field is required.
Yes
No
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Please select all personality disorders that apply* This field is required.
Antisocial Personality
Avoidant Personality
Borderline Personality
Dependent Personality
Histrionic Personality
Narcissistic Personality
Obsessive-Compulsive Personality
Paranoid Personality
Schizotypal Personality
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Does patient have a primary care provider?
YESNO
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Primary care provider details* This field is required.
First and Last Name
Office Phone Number
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Is there a history of psychiatric hospitalization?* This field is required.
Yes
No
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List previous psychiatric hospitalization(s) with dates* This field is required.
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Are there any current medical problems?* This field is required.
Yes
No
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Please list current medical problems* This field is required.
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Please list current medications* This field is required.
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Please list previous medications which have been tried and failed* This field is required.A failed medication is one that caused a negative, unacceptable side effect, or one that did not work effectively.
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Is there current substance use?* This field is required.
YESNO
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Please select all substances that apply.* This field is required.
Prescription Medications (other than your own)
Street Drugs (Illegal Substances)
Other
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Please describe the substance use patterns.* This field is required.Enter details about your substance use including frequency.
Enter whether you engage daily, weekly, occasionally.
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Alcohol consumption?* This field is required.
Yes
No
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How often has the consumption of 5 or more alcoholic beverages in a single sitting occurred during the past 30 days?* This field is required.
Never
Occasionally
Frequently
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Never
Row 0, Column 0
Occasionally
Row 0, Column 1
Frequently
Row 0, Column 2
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Is marijuana (THC) being used?* This field is required.Answering YES will not automatically disqualify you from becoming a patient.
Yes
No
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Marijuana (THC) use frequency.* This field is required.
Less than monthly
Monthly
Weekly
2-3 times a week
4-6 times a week
Daily
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Less than monthly
Row 0, Column 0
Monthly
Row 0, Column 1
Weekly
Row 0, Column 2
2-3 times a week
Row 0, Column 3
4-6 times a week
Row 0, Column 4
Daily
Row 0, Column 5
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Medication History Review: I understand that Tulsa Family Psychiatry & Wellness routinely reviews medication history through the Oklahoma Prescription Monitoring Program (PMP) and SureScripts as part of clinical evaluation, patient safety, and medication management.* This field is required.
Yes, I understand.
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I understand that providers at Tulsa Family Psychiatry do not recommend ongoing treatment with benzodiazepines.* This field is required.Benzodiazepines include: Alprazolam (Xanax), Clonazepam (Klonopin), Diazepam, (Valium) Lorazepam, and several others.
Yes, I understand
No, I do not understand
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Benzodiazepines are medications used to treat anxiety, insomnia, seizures, muscle spasms, and other conditions. Although effective, particularly for short-term use, they carry significant risks, especially with prolonged use.

Dependence, Tolerance & Withdrawal: Regular use can lead to physical or psychological dependence and reduced effectiveness. Abrupt discontinuation can cause severe anxiety, insomnia, tremors, and potentially life-threatening seizures.

Cognitive Impairment: Memory problems, difficulty concentrating, and slowed thinking may occur. Some effects may persist after discontinuation.

Falls & Injuries: Sedation and impaired coordination increase fall and injury risks, particularly in older adults.

Respiratory Depression & Overdose: Combining benzodiazepines with alcohol, opioids, or other sedatives can dangerously suppress breathing and cause fatal overdose.

Behavioral Changes: Some patients experience increased anxiety, agitation, aggression, or hallucinations.

Rebound Symptoms: Anxiety or insomnia may temporarily worsen when medication is reduced or discontinued.

Other Long-Term Concerns: Research suggests a possible association with dementia, although causation remains unproven. Use during pregnancy may pose risks to the developing baby.

Important: Benzodiazepines should never be stopped abruptly without medical guidance.
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How did you hear about us?* This field is required.
Google
Therapist
Pediatrician
Other healthcare provider
Friend or Family Member
Other
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Form submitter's signature* This field is required.
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