HOMEPAGE INTAKE

Brief Intake Form

This is a HIPAA compliant form that includes symptoms, consent policies. Completion of this form does not guarantee a treatment relationship is established. The more thorough the information provided, the better we will be able to assist you. If you are having an emergency, please contact 911 immediately
📌 Priority Notice

Priority is given to patients who complete the form thoroughly. Incomplete submissions may delay scheduling and insurance verification. If partial incomplete information is provided, we may not be able to reach out in a timely manner.
Mental Health Status and History
What issues or problems are you currently experiencing?
Select which items you think are affecting your quality of life.

attention deficit hyperactivity disorderbipolar disorderdepressionanxietyperceptual disturbance/psychosis/schizophreniaobsessive compulsive disorderpost-traumatic stress disordereating disorderpersonality disorderneurocognitive decline / memory issuessleep problemsOther
Current Medications and Treatments:
Previous medication trials (psychiatric or medical), surgeries, allergies, and any prior medical diagnoses:
Addiction/Substance Use History? Please include cannabis products, nicotine products, caffeine, herbal supplements, prescription and illicit drugs.
Notable Family Medical History and/or Family Psychiatric History
Desired Appointment TIme*
Appointment Type

TelephoneIn-Office Appointment
Current address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INSURANCE COMPANY (REQUIRED TO START VERIFICATION OF BENEFITS)*
MEMBER ID NUMBER*
UPLOAD YOUR INSURANCE CARD HERE (must be submitted to consider appointment)

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Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
I confirm all information in this form is true and accurate. I also understand that all data in this form will be strictly confidential. I have reviewed and agree to the consent policy and the release of information policy linked blow. We may share limited contact details with third-party software providers to facilitate scheduling, billing, or other care-related tasks. Your protected health information (PHI) remains stored and processed on HIPAA-compliant platforms in accordance with federal regulations. If you have any questions or concerns, please call/text us at 910-310-8376 or email at info@psychwellnow.com. *

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Brief Intake Form

Mental Health Status and History