Appointment Request Form - Laurel Psychiatry

Appointment Request Form
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?*
Reason for Seeking Services*
Which services have been recommended to you?*

Outpatient Therapy or PsychiatryIntensive Outpatient ProgramPlease help me decide
What services are you looking for?*

Individual TherapyParent and/or Family TherapyPsychiatry
Have you ever been evaluated by a psychiatrist?*

YesNo
If yes, please list any past psychiatric diagnoses you have received*
Are you currently taking any psychiatric medications?*

YesNo
If yes, please list the medications (include name, dose, and frequency):*
Have you participated in any psychiatric medication trials in the past?*

YesNo
If yes, please describe the medications and your experience (e.g., name, duration, outcome):*
Have you received psychotherapy in the past or are you currently in therapy?*

YesNo
If yes, please provide the name of the therapist(s):*
How did you hear about my practice?*
Please Note:

Although my practice does not accept insurance, I request your insurance information to help determine whether prior authorization may be required for certain treatments.
Please Select Your Insurance Carrier*
Should be Empty: