New Patient Request Form

New Patient Request Form
Thank you for your interest in becoming a patient at Joyful Mind Psychiatry. To ensure we can provide the best care for you or your child, please fill out the form below. If you are a parent or guardian completing this form, please include your details in the appropriate sections. If any additional information is needed, we will reach out to you.
Patient Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Patient Age*
Gender*
Preferred Pronouns
Parent/Guardian Name
Relationship to Patient
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number*
Email*
Primary Insurance Carrier*
What services are you seeking from Joyful Mind Psychiatry? (select all that apply)*

Diagnostic EvaluationMedication ManagementIndividual TherapyIntegrative Psychiatry (Medication + Therapy)Autism Evaluation (Age 12+)ADHD Evaluation (Age 10+)
Where would you like to receive services?*
Briefly describe your primary concerns or goals for treatment.*
Please list any medications currently taken for medical and/or mental health.*
Is there anything else you'd like to share?
Should be Empty: