Clone of Clinical Intake Process Form

Welcome to Your Journey to Better Sleep!
Eligibility at a Glance

New to SleepScriptMD
• I’m a new patient seeking prescription options for sleep.

Adult, 18–65
• I am between 18 and 65 years old.

Not Pregnant
• I’m not pregnant and not planning pregnancy.

No Ongoing Prescriptions
• I haven’t needed ongoing prescription treatment for medical, mental-health, or substance-use conditions for 4+ years. (Short courses like antibiotics, birth control, topicals, and routine vitamins/supplements are OK.)

No Untreated Sleep Apnea
• I do not have untreated sleep apnea or significant nighttime breathing problems.

Not Seeking Controlled Meds
• We don’t prescribe benzodiazepines (Ativan, Xanax, Klonopin) or Z-drugs (Ambien, Lunesta, Sonata); we focus on safer, non-addictive treatments.

Fees Don’t Include Medication
• Program fees (intake/subscription) exclude the medication; I’ll fill at my local pharmacy. (Starter Rx often < $10—check GoodRx.com.)

Pharmacy Safety Check
• SleepScriptMD will verify my eligibility through pharmacy records. If current meds make treatment unsafe, I understand I’m not eligible and the intake fee is non-refundable.
Do you meet all the above criteria?*

YesNo, I’m a Returning PatientNo, I would like to become a new patient, but I do not meet one or more of the above criteria.
Due to ethical considerations and liability insurance restrictions, our virtual treatment services are not permitted for patients with these risk factors. However, if you believe your situation involves unique circumstances, please feel free to reach out to us at Admin@SleepScriptMD.com.

Where We Operate: State Eligibility
Synchronous vs Asynchronous Care by State

SleepScriptMD is available in 40+ states. Most allow fully asynchronous care—just complete your intake, no appointment needed.

However, 16 states require a brief virtual visit before we can prescribe.
Check the map below to see what applies in your state.

Not available in your state yet? Join our waitlist—we’re expanding fast.
Where do you currently reside?*
⚠ Required Virtual Appointment for Your State

Due to your state’s regulations, your first visit with SleepScriptMD must include a brief video appointment with a licensed provider.
- Cost: $95 (includes the appointment and, if appropriate, a 30-day prescription)
- Length: 5–20 minutes
- Scheduling: Book at the end of this intake — most are available within 2 business days.
After this one-time video visit, most follow-ups can be done asynchronously — no future appointments required unless you request one.
What state are you in?*
If you want us to notify you when we launch in your state, enter your email below.
example@example.com
Great! We are fully licensed to provide quality sleep care in your state. Please continue!

Choose Your Preferred Medication
Choose one of three non-addictive sleep medications. Click each card to see how it works, key pros/cons, and who it tends to fit best. Make your provisional choice; after reviewing your intake, your SleepScriptMD clinician will confirm and start with the lowest safe dose.

Clonidine (Catapres • Kapvay • Onyda XR)Trazodone (Desyrel • Oleptro)Hydroxyzine (Vistaril)I have tried all three (in which case you must do a virtual appointment, which you can schedule upon completion of this clinical intake form)
Clonidine (Catapres • Kapvay • Onyda XR)

Great for: racing thoughts, stress/ADHD-related insomnia
- Starting dose: 0.05 mg at bedtime (range 0.05–0.3 mg)
- How to take: 30–60 min before bed; rise slowly
- Common effects: dry mouth, lightheadedness, tiredness
  🔗 See all side effects
- Avoid/Use caution: very low blood pressure, fainting tendency, multiple BP meds
- Interactions: other sedatives/alcohol (extra drowsy), stimulants (BP swings), beta-blockers (special taper needed if stopping clonidine)
- Why pick this: non-addictive; calms hyperarousal; helpful in ADHD-related sleep issues
Trazodone (Desyrel • Oleptro)

Great for: staying asleep / fragmented sleep
- Starting dose: 25–50 mg at bedtime (range 25–200 mg)
- How to take: allow ~8 hours for sleep
- Common effects: morning grogginess (~10%), dizziness, dry mouth
  🔗 See all side effects
- Rare risks: priapism (prolonged, often painful erection lasting >4 hours—medical emergency), serotonin syndrome with serotonergic meds
- Use caution: personal/family history of heart-rhythm issues (QT), pregnancy/breastfeeding
- Why pick this: enhances deep (slow-wave) sleep; non-controlled; affordable
Hydroxyzine (Vistaril)

Great for: anxiety-related insomnia (falling and staying asleep)
- Starting dose: 25 mg at bedtime (range 25–100 mg)
- How to take: 30–60 min before bed
- Common effects: drowsiness, dry mouth, dizziness; possible a.m. grogginess
  🔗 See all side effects
- Avoid/Use caution: long-QT history, pregnancy; older adults may be more sensitive
- Interactions: other sedatives/alcohol (excess drowsiness), QT-prolonging meds
- Why pick this: non-addictive; fast-acting; versatile

Almost there — next is secure payment
After payment, you’ll complete the brief clinical questions, add your pharmacy information, and sign the consent form so we can finalize your evaluation.

What your one-time fee covers:
- A thorough asynchronous medical review to confirm safety and fit for non-controlled sleep options
- Processing and electronic delivery of your prescription to your chosen pharmacy (if appropriate)
Timeline: Once you complete the post-payment steps, a licensed clinician reviews your intake and—if appropriate—submits the prescription within 1 business day. No phone or video visit required.

Note: The fee does not include the cost of the medication itself.

Choose Your Preferred Treatment Approach

💊 Your First 30-Day Prescription: Just $25(Limited-Time Offer – Save Over 40%! Regular monthly fee is $42)

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🤝 Prefer to Speak With Someone First?Choose a 10–20 minute virtual intake appointment for $110 instead. A provider will walk you through everything in real time.

$110.00

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Cancellation Agreement: By checking "I agree" below, you acknowledge and accept our strict cancellation policy. If you need to cancel or reschedule your appointment, you must notify our office at least 2 full business days in advance (please note that weekends do not count as business days). Failure to provide sufficient notice will result in being charged the full price of the consultation, as time is specifically set aside for you with our Medical Practitioners, which represents a significant cost to our practice.*

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Demographics
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Proof of Identity: Please take a selfie with your photo ID next to your face.*

Emergency Contact
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Relationship to you?*

Personal Health Information
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We're Sorry — SleepScriptMD Is for Adults Only

Due to ethical and legal regulations, we are unable to provide treatment to individuals under the age of 18 at this time.

If you entered your age incorrectly, you can hit “Back” to update it.

Otherwise, we recommend speaking with a pediatrician or adolescent mental health provider who can offer developmentally appropriate care.

Health Concerns, Past & Present
Have you ever—past or present—experienced any significant medical, mental health, or substance use issues that required or might have benefited from treatment? (Examples: depression, anxiety, heart or lung conditions, substance or alcohol misuse, hospitalizations, etc.)*

YesNo
Please describe each issue, when it occurred, what treatment (if any) you received, and why treatment ended or wasn’t pursued.*

Medications & Supplements (Past and Present)

Most people have taken a medication or supplement at some point—this is totally normal. Please let us know if you’ve used any.
Have you ever used (or are you currently using) any prescription meds, over-the-counter meds, or supplements?

YesNo
Previous Medications & Supplements
List anything you used in the past. Include name, approximate dates, dose (if known), and why you stopped.
Current Medications & Supplements
List anything you’re using now. Include name, dose (if known), and how often you take it.

Drug Allergies
Do you have any known drug allergies?*

YesNo
Please provide more information of any known drug allergies you have.*
If you have had an allergy to a supplement, please list the supplement name and the related reaction below.

Choosing Your First Sleep Medication
You’ve Already Chosen a Starting Medication — Confirm Once More Below '
- Tap your medication again to see a clear overview: what it does, key benefits/trade-offs, dosing, and common side effects.
- These are first-line, non-controlled sleep treatments.
- Typical cost: often under $10 at many pharmacies — compare prices on GoodRx.com.
- After you confirm, your SleepScriptMD clinician will review your intake and safety checks, then prescribe the lowest safe starting dose to your pharmacy.
Choose Your Medications

ClonidineHydroxyzine (Vistaril)Trazodone
Clonidine

Brand Name: Catapres
Available Doses: Immediate-release tablets: 0.1 mg, 0.2 mg, and 0.3 mg

Minimum / Maximum Dose: 0.05 - 0.3 mg nightly

What is Clonidine?
Clonidine is a centrally acting alpha-2 adrenergic agonist that was originally developed to lower blood pressure. Over time, its off-label uses have expanded significantly. It is now frequently prescribed to manage insomnia, anxiety, ADHD, and even opioid withdrawal symptoms. By reducing sympathetic nervous system activity, clonidine induces a calming, sedative effect, which makes it effective for sleep.

Additionally, clonidine is used in some cases for post-traumatic stress disorder (PTSD), tics (Tourette’s syndrome), and hot flashes related to menopause. Emerging research also explores its role in mitigating inflammatory responses, making it a topic of interest in conditions like Long COVID.

The Doctors’ Insights
In clinical practice, clonidine is an effective and underutilized sleep aid, especially for individuals who struggle with racing thoughts, stress-related insomnia, or ADHD-related sleep disturbances. It works quickly, helping patients fall asleep within 30 to 60 minutes without the risk of addiction or tolerance buildup.

Unlike some sedative medications, clonidine rarely causes morning grogginess because it lacks the lingering effects of drugs like trazodone or certain antihistamines. However, it is not ideal for everyone. Some individuals experience dizziness, dry mouth, or mild next-day fatigue, especially at higher doses.

For those with ADHD, clonidine provides additional benefits beyond sleep, including reduced hyperactivity, improved impulse control, and decreased emotional reactivity. Because of its blood pressure-lowering properties, it is not recommended for patients prone to dizziness or fainting unless closely monitored.

Pros:
- Non-addictive with no risk of misuse.
- Sedative properties can aid in falling asleep, especially for individuals with ADHD or anxiety related insomnia.
- Available in multiple forms (tablet, patch).
Cons:
- Common side effects include dry mouth, dizziness, fatigue, and constipation.
- Abrupt discontinuation of high doses taken multiple times per day (which is not how we prescribe it) can result in withdrawal symptoms, such as rebound hypertension.
- It can occasionally cause low blood pressure. Therefore, caution is advised for patients with naturally low blood pressure, a tendency to feel dizzy upon standing suddenly, or a history of fainting (syncope).
All Side Effects

Medications to Avoid with Clonidine
Certain drugs can increase side effects or pose risks when combined with clonidine:
- Other blood pressure medications → Risk of excessively low blood pressure (hypotension)
- Sedatives and sleep aids → Increased drowsiness (benzodiazepines, alcohol, antihistamines, opioids)
- Stimulants (ADHD meds like Adderall, Ritalin) → Can cause blood pressure fluctuations when combined
- Beta-blockers → Risk of severe blood pressure drops if clonidine is stopped suddenly
Always consult your provider before combining clonidine with other medications.
Hydroxyzine

Brand Name: Vistaril

Available Doses: 25 mg and 50 mg capsules or tablets.
Minimum / Maximum Dose: 25 - 100 mg at bedtime.

What is Hydroxyzine?
Hydroxyzine is an antihistamine commonly prescribed for its calming and sedative effects. It is used to treat anxiety, insomnia, itching from allergies, nausea, and even mild pain relief. It works by reducing central nervous system activity and blocking histamine, which causes allergic reactions. Unlike benzodiazepines, hydroxyzine is non-addictive and does not lead to dependence, making it a safer option for long-term use.

The Doctors’ Insights
Hydroxyzine is a versatile medication that effectively helps both falling asleep and staying asleep. It is particularly useful for individuals who struggle with anxiety-related insomnia, as it promotes relaxation without the risk of dependence seen with other sleep aids.

One of the key benefits of hydroxyzine is its fast-acting sedative effect, making it a reliable option for those who have difficulty initiating sleep. Additionally, it helps maintain sleep by reducing nighttime awakenings. Unlike some stronger medications, it does not disrupt normal sleep cycles, allowing for a more natural rest.

However, about 10% of patients report mild morning tiredness as the medication gradually leaves their system. This effect is typically dose-dependent and can often be minimized by adjusting the dosage or taking it earlier in the evening. When used correctly, hydroxyzine provides a safe, non-addictive alternative for improving sleep quality.

Pros and Cons of Hydroxyzine

Pros:

✔ Non-addictive with no risk of dependence.
✔ Fast-acting sedative effects help with sleep onset.
✔ Available as a low-cost generic option.
✔ Versatile uses (anxiety, allergies, nausea, insomnia).

Cons:
✖ Can cause significant drowsiness, dizziness, and dry mouth.
✖ Not suitable for individuals with long QT syndrome or during pregnancy.
✖ May lead to confusion or oversedation in older adults.

Medications to Avoid with Hydroxyzine
Some medications can interact with hydroxyzine, increasing the risk of side effects or adverse reactions:
- Central nervous system depressants (risk of excessive drowsiness): Benzodiazepines, opioids, alcohol, sleep aids.
- QT-prolonging drugs (risk of heart arrhythmias): Certain antibiotics, antipsychotics, antiarrhythmic.
- Antihistamines (risk of enhanced side effects): Diphenhydramine, promethazine.
- CYP3A4 inhibitors (may increase hydroxyzine levels): Some antifungals, antibiotics, HIV medications.
Always inform your provider about your medications to avoid potential interactions.

Common Effects:
✔ Mild relaxation and drowsiness.
✔ Reduction in nighttime awakenings.
✔ Potential morning grogginess, usually improving over time.

Uncommon Effects:
✖ About 5% of patients report mild confusion or dizziness.
✖ Rare cases of dry mouth, headache, or nausea.
✖ If side effects occur, notify your provider for adjustments.

View All Side Effects Here
Trazodone

Brand Names: Desyrel, Oleptro

Available Doses: 50 mg, 100 mg, and 150 mg tablets (immediate-release).
Minimum / Maximum Dose: 25 to 200 mg at bedtime.
What is Trazodone?
Trazodone is an antidepressant that is often prescribed off-label for insomnia due to its sedative properties. It works by modulating serotonin, a brain chemical that influences mood and sleep. Trazodone is also used to treat depression, anxiety, and certain behavioral issues.
The Doctors’ Insights

Trazodone is one of the most widely preferred and frequently used treatments for insomnia, offering an effective, safe, and non-addictive option. One of its standout benefits is its ability to enhance deep, slow-wave sleep—the most restorative sleep stage, essential for physical recovery, cognitive function, and emotional well-being.

Trazodone works by modulating serotonin levels while also blocking histamine and alpha-adrenergic receptors, promoting relaxation and deep sleep.

Because it has a lower potential for abuse compared to many other sleep aids, trazodone is often considered a safer long-term option for individuals needing consistent sleep support. Its sedative effects help with both falling asleep and staying asleep, making it particularly beneficial for those with fragmented sleep patterns.

That said, approximately 10% of patients report mild "morning hangover" effects, experiencing grogginess or sluggishness for the first hour after waking. Additionally, about 5% of patients may experience temporary dysphoria or irritability. If these side effects occur, it is important to monitor symptoms and discuss potential dose adjustments or alternative treatments with your provider.

When taken correctly, trazodone provides an effective, non-habit-forming solution for improving sleep quality, helping many patients achieve deeper, more refreshing rest.

Pros & Cons

✔ Pros:

Enhances slow-wave sleep

Non-addictive; not a controlled substance

Effective for sleep maintenance

Affordable compared to other sleep aids

✖ Cons:

Possible daytime drowsiness, dizziness, dry mouth

Rare risks: priapism (prolonged painful erection), serotonin syndrome (especially with other serotonergic drugs)

May increase suicidal thoughts in young adults

View All Side Effects Here

Medications to Avoid with Trazodone

Certain drugs can increase side effects or pose risks:

Serotonergic drugs (risk of serotonin syndrome): SSRIs, SNRIs, MAOIs, tramadol, St. John’s wort

Other sedatives (excessive drowsiness): benzodiazepines, opioids, alcohol, sleep aids QT-prolonging drugs (heart arrhythmias): some antibiotics, antipsychotics, antiarrhythmics

CYP3A4 inhibitors/inducers (altered trazodone levels): antifungals, antibiotics, HIV meds, rifampin

Always inform your provider about your medications.

Pregnancy and Breastfeeding Considerations

Pregnancy

Trazodone is not recommended during pregnancy due to limited human studies and potential risks, including effects on fetal development. While some providers may consider it in specific cases, our policy does not support prescribing trazodone if pregnancy occurs. Patients who are pregnant or planning pregnancy should consult their doctor for safer alternatives for sleep management.

Breastfeeding

Trazodone passes into breast milk in small amounts, but its effects on infants remain unclear. Reports suggest possible sedation, poor feeding, and respiratory issues in breastfeeding infants. Our policy does not support the use of trazodone while breastfeeding. Patients should discuss alternative options with their healthcare provider.

Medication Information & Consent

Below is detailed information on your medication’s benefits, dosing, and potential side effects. Review it carefully, and if you have further questions, you can set up a virtual intake appointment at the end of the clinical survey.
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Pharmacy Information
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💊 You’ll pay for your medication separately at your chosen pharmacy.

💰 No insurance? Check GoodRx.com for big discounts. Enter your zip code + medication to compare local pharmacy prices, then add your preferred pharmacy’s phone number below.
Pharmacy Phone*
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SleepScriptMD Patient Agreement: Treatment, Privacy, and Financial Policies
Last step—almost done! 🎉
Please review this short agreement so we can get started on your chosen treatment right away.

This agreement explains your treatment plan, privacy protections, and financial policies in clear terms.

Read carefully and sign below—your signature confirms consent to treatment and acknowledgment of these policies.

☑️ When you sign, we’ll immediately move your intake forward and prepare your prescription plan for clinician review.
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Welcome to Your Journey to Better Sleep!

Where We Operate: State Eligibility

Choose Your Preferred Medication

Almost there — next is secure payment

Demographics

Emergency Contact

Personal Health Information

Health Concerns, Past & Present

Medications & Supplements (Past and Present)

Drug Allergies

Sleep Assessment Questionnaire

Choosing Your First Sleep Medication

Medication Information & Consent

Pharmacy Information

SleepScriptMD Patient Agreement: Treatment, Privacy, and Financial Policies