Form
SELF SCREENING TOOL FOR NEW PATIENTS
Thank you for your interest in Integrative Psychiatry Austin. In order to determine whether we are a good fit for your mental health needs, please answer the following questions in order to receive a New Patient Information packet. Included in this packet will be instructions on making your first appointment.
Name (if you are looking for help for a minor please fill the minor's name)
*
First Name
Last Name
Date of Birth (if you are looking for help for a minor please fill the minor's date of birth)
*
-
Month
-
Day
Year
Date
Pronouns
Email
*
example@example.com
Zip code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
1) What is the problem or goal for which you’re seeking guidance?
*
2) Have you ever been hospitalized for a mental health diagnosis?
*
3) Have you felt suicidal or contemplated self-harm in the past 3 years?
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Yes
No
4) If yes to #3, please give us more information.
5) Are you looking for a consult or establish long term care?
*
Please Select
Consult
Long term care
Both
6) Our clinic has a unique advantage of having multidisciplinary team assessments. indicate the assessments. Please select the assessments you are interested in.
Medication management
Herbal medicine
Functional medicine
Nutritional medicine
Neuropsychological and Academic testing
Psychotherapy
Ketamine Assisted Psychotherapy
Health and Wellbeing coaching
I am open to suggestions
7) We can provide multidisciplinary assessments online as well. Are you interested in seeking care
Online
In-person
Sometimes online and sometimes in person
8) If the patient is a child, are both parents in agreement that the child be evaluated and treated?
*
Yes
No
Not applicable
More information about the above answer (optional)
9) Who referred you to us?
*
10) Please provide us additional details on the situation that brings you in for guidance, if medication management is involved please provide current medication and dosage. Please note that our practice does not prescribe benzodiazepines. Is there anything else about your mental health needs that you want us to know?
Please check this box giving us permission to email or text you to help coordinate your care.
*
Yes
No
Submit
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