• Carencia New Patient Form | Part 2

  • Before We Begin

    This is part 2 of 2. In order for your visit to be the best experience possible, please complete this form prior to your first visit.

    Note: We recommend completing this form on your computer. If you have issues, please try the following:

    • Clear your browser history/cookies.
    • Check for browser updates
    • Try viewing the website in private/incognito mode.


    If you are having trouble with the form or have questions, please contact us at welcome@carencia.com.

  • Date of Birth of Patient (Enter the Same Date of Birth as Part 1)*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Would you like to share your pharmacy information?

  • Pharmacy

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Symptom Questionnaire

  • Would you like to complete a mental health symptom assessment covering several common areas of possible concern?*

  • The questions below are about things that might have bothered you. For each question, check the box next to the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.

  • During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems?

  • Understanding and Communicating*
    Rows

  • Medical History

    Please list all the medications and supplements you currently take, including the dose, instructions, and the reason for taking.
  • Are you currently taking any medications and/or supplements?*
  • Current Medications/supplements*
  • Do you have any drug allergies?*
  • Drug Allergies*
  • Have you been diagnosed with a medical illness and/or have medical conditions?*
  • Medical Illnesses*

  • Treatment History

  • Would you like to provide your mental health treatment and substance history now or at the time of the visit?*
  • Do you have any history of psychiatric treatment including, but not limited to medications, therapy, or hospitalizations?*
  • Have you taken medications for mental health or substance use reasons that you are not currently taking?*
  • PREVIOUS MEDICATIONS*
  • Have you had previous mental health treatment other than medication?*
  • PREVIOUS MENTAL HEALTH TREATMENT*
  • Have you had any treatments other than therapy or medicine such as TMS or Biofeedback for mental health or substance use related reasons?*
  • OTHER TREATMENTS*

  • Substance Use History

  • Do you have any current misuse, abuse or dependence of substances?*
  • Do you have any previous misuse, abuse or dependence of substances?*
  • Please List Substance History*
  • Have you had any treatment for substance use?*
  • TREATMENT FOR SUBSTANCE USE*

  • Family History

  • Does your family have any history of medical conditions, mental health conditions or substance use?*
  • Family History*
  • Should be Empty: