TSTS | New Patient Questionnaire

Name:*

FirstLast
Phone:*
Include area code
Date of birth:*

MonthDayYear
Age:*
Address:*

Address Line 1

Address Line 2

CityState

ZIP
Email:*
TO THE PATIENT:

Your medical record is confidential will not be released to a third party without your approval unless:
- You are at a risk of committing harm to yourself or another person
- You are at risk of harm (abuse or neglect) by another person
- You are experiencing a medical event and it is considered an emergency
- You require emergency mental health screening and/or hospitalization.
A release of information for an emergency contact may be requested.

INITIAL THE FOLLOWING STATEMENTS:
1. I understand my signature will be required for proof of attendance for services.*
2. I understand failure to keep my scheduled appointment may result in termination of services.*
Signature*

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PATIENT QUESTIONNAIRE