New Patient Request Form

New Patient Request
N&I Psychiatry

www.nipsychiatry.com P:(904) 394 3232 F: (904) 541 9209
Welcome to N&I Psychiatry. If you are interested in becoming a new patient or have received a referral to our practice for mental health services, we kindly ask that you complete the appointment request form. Upon review of your request, we will evaluate whether our services suit your needs. If your request is approved, our office will reach out to you to schedule an appointment.
Patient Name

First NameLast Name
Birth Date

MonthDayYear
Age
Birth Sex

MaleFemaleOther
Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason For Appointment Request

DepressionAnxietyMedication ManagementOCDADHD/ADDMedication for Mental Health is being consideredTalk Therapy/PsychotherapyPTSDOther
ADHD: Please indicate if you have been formally diagnosed, had a neuropsychological evaluation and what medications you have tried in the past.
Addiction: Please indicate which of the following apply:

AlcoholCaffeineBenzodiazepinesCannabisHallucinogensHypnoticsInhalantsOpioidsStimulantsTobaccoOther
Are you currently out of work or planning to be out of work soon due to mental health?

NoYes
If yes, Please describe in detail:
List of Names of ALL current prescribed medications
Were You Referred By a Provider?

YesNo
Name of Referring Provider
Name of Current Therapist
Name of Current Primary Care Provider (PCP)
Primary Insurance Provider
Primary Insurance Policy Number
If Other Insurance, Please indicate insurance company
Secondary Insurance Provider
Secondary Insurance Policy Number
Please attach a copy of the front and back of your insurance card(s)

Cancelof
About Our Services:

N&I Psychiatry Medication Managment and support therapy-

outpatient office and virtual services

N&I Psychiatry we are committed to providing compassionate and personalized care to our patients. We believe that mental health is just as important as physical health, and we strive to help our patients achieve optimal wellbeing. Our team of experienced psychiatrists uses evidence-based practices to diagnose and treat a wide range of mental health conditions, including depression, anxiety, bipolar disorder, insomnia, PTSD and other mood disorders. We believe in a holistic approach to mental health treatment, addressing not just your symptoms but also the underlying causes.

To learn more about our services please visit www.nipsychiatry.com or call 904-394-3232.
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New Patient Request

N&I Psychiatry