Appointment Request Form - Epionique Healthcare

Appointment Request Form

Epionique Healthcare
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Today's Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Age Confirmation*
Please review and make sure this is the correct age of the patient. If not, please correct the date of birth.
Parent/Guardian Name*

First NameLast Name
What is your email address?*

Confirmation Emailexample@example.com
What is your mobile phone number?*
What brings you to seek consultation at this time?*

Mental Health Concerns (Depression, Anxiety, Panic attacks, Anger, Aggression, ADHD)Substance UseBoth
Please elaborate on your reason for seeking consultation*
What services are you looking for?*

Individual TherapyPsychiatry
Has your child ever been diagnosed with a psychiatric condition or received mental health treatment (therapy, medications, or hospitalization)?*
Has your child ever had any thoughts of self-harm, suicide, or shown self-injurious behavior?*
Does your child have any medical, neurological, or developmental conditions—such as seizures, head injuries, heart conditions (including murmurs), asthma, or other diagnoses—that might affect their behavior or treatment?*
Are there any current or past legal issues, school concerns (such as IEPs, suspensions), CPS involvement, or guardianship arrangements we should be aware of?*
Has your child ever tried any psychiatric medications before? If so, which ones and how did they respond?*
Which services have been recommended to you?*

Outpatient Therapy or PsychiatryIntensive Outpatient ProgramPlease help me decide
How did you hear about us?*
Please Select Your Insurance Carrier*
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