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Important Information: Jacob Scott, PMHNP-BC does not prescribe stimulants for ADHD (adderall, vyvanse, ritalin...) or benzodiazepines for anxiety (ativan, xanax, klonopin ....)
Preferred Provider

Dr. Stacy StuartJacob Scott, PMHNP-BC
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
For clients age below the age of 14: Guardian must be present during appointment.

The legal age of consent in Alabama is 14. Consent for treatment will be obtained from the patient and information regarding their care cannot be released without their permission.

If clients are above the age of 14, but you have guardianship of the client, please submit guardianship papers to this office.
Guardianship Documentation

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Reason for visit: Please explain why you are seeking treatment.
Psychiatric History: 1. Any mental health providers? 2. Any past medications for mental health? 3. Any past mental health diagnosis? 4. Any hospitalizations related to your mental health?
Family History of Mental Health: Please list any family members with mental health issues that you know about.
Substance UseTobacco use? Alcohol use? Any history of or current issues with substance abuse?
Social History: 1. Who do you live with? 2. Number of children 3. Married/single? 4. Job 5. Level of education?
Current Medications:
Medical and Surgical History:
Primary Care Physician. Please also list any other providers/specialist you see on a regular basis
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Allergies
Please upload front and back of ID

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