Clone of v1.3 In-Take Form

Where are you located?*
Select your state
What can we help you with?*

Initial EvaluationMedication ManagementInjured WorkerNot sure / Something else
Medication Management*

I’m already taking prescribed medicationI need a new prescriptionNot using medication
Current Medication(s)
What do you take this medication for?*
What brings you here today?*
Do you have health insurance?*
Who is this appointment for?*

MyselfMy childSomeone else (dependent)
I am a:*

IndividualProviderEmployerCase ManagerAttorneyOther
Have you worked with PAX before?*

Yes, I have an existing relationship or portal access.No, this is my first time
What best describes your situation?

Work-related injury / Workers’ compensation caseDisability claimMotor vehicle accident (no-fault)
Name*

First NameLast Name
Email*
john@pax.health
Phone Number
Please enter a valid phone number.
Provide Case Details
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth

MonthDayYear
Date
Gender as listed on insurance

FemaleMaleDecline to SpecifyOther
How did you hear about us?
When are you generally available for appointments?*

Early morning (8–10 AM)Late morning (10 AM–12 PM)Afternoon (12–4 PM)Evening (after 4 PM)Flexible / Anytime
Gender preference
Language preference
To access the portal and continue working on your case Click here
To access the portal and continue working on your case Click here
To access the portal and continue working on your case Click here
Should be Empty:

Alprazolam (Xanax)
Amitriptyline (Elavil)
Amphetamine/Dextroamphetamine (Adderall, Mydayis)
Aripiprazole (Abilify)
Asenapine (Saphris)
Atomoxetine (Strattera)
Brexpiprazole (Rexulti)
Bupropion (Wellbutrin, Zyban)
Buspirone (Buspar)
Carbamazepine (Tegretol, Carbatrol)
Cariprazine (Vraylar)
Chlordiazepoxide (Librium)
Chlorpromazine (Thorazine)
Citalopram (Celexa)
Clomipramine (Anafranil)
Clonazepam (Klonopin)
Clonidine (Kapvay)
Clozapine (Clozaril)
Desipramine (Norpramin)
Desvenlafaxine (Pristiq)
Dexmethylphenidate (Focalin)
Dextroamphetamine (Dexedrine, Zenzedi, ProCentra)
Diazepam (Valium)
Doxepin (Silenor, Sinequan)
Duloxetine (Cymbalta)
Escitalopram (Lexapro)
Eszopiclone (Lunesta)
Fluoxetine (Prozac)
Fluphenazine (Prolixin)
Fluvoxamine (Luvox)
Gabapentin (Neurontin – off-label use for anxiety)
Guanfacine (Intuniv)
Haloperidol (Haldol)
Hydroxyzine (Vistaril, Atarax)
Imipramine (Tofranil)
Isocarboxazid (Marplan)
Lamotrigine (Lamictal)
Levomilnacipran (Fetzima)
Lisdexamfetamine (Vyvanse)
Lithium (Eskalith, Lithobid)
Lorazepam (Ativan)
Loxapine (Loxitane)
Lurasidone (Latuda)
Methylphenidate (Ritalin, Concerta, Daytrana, Metadate)
Midazolam (Versed)
Mirtazapine (Remeron)
Nortriptyline (Pamelor)
Olanzapine (Zyprexa)
Oxcarbazepine (Trileptal)
Paliperidone (Invega)
Paroxetine (Paxil)
Perphenazine (Trilafon)
Phenelzine (Nardil)
Propranolol (Inderal – off-label for performance anxiety)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Selegiline (Emsam – transdermal patch)
Sertraline (Zoloft)
Temazepam (Restoril)
Thioridazine (Mellaril)
Topiramate (Topamax)
Tranylcypromine (Parnate)
Trazodone (Desyrel, Oleptro)
Triazolam (Halcion)
Trifluoperazine (Stelazine)
Valproic acid / Divalproex sodium (Depakote)
Venlafaxine (Effexor)
Vilazodone (Viibryd)
Vortioxetine (Trintellix)
Zaleplon (Sonata)
Ziprasidone (Geodon)
Zolpidem (Ambien)

ADHD
Addiction
Anger Management
Anxiety
Bipolar Disorder
Career Counseling
Child or Adolescent
Coping Skills
Couples Counseling
Depression
Dissociative Disorders
Domestic Violence
Eating Disorders
Family Conflict
Family Therapy
Foster Care/Adoption
Grief
Insomnia/Sleep Issues
Learning Disabilities
LGBTQ
Life Transitions
Men's Issues
Military/Veterans
Mood Disorders
Obsessive-Compulsive (OCD)
Older Adults
Parenting
Peer Relationships
Personality Disorders
Phobias
Post Partum
Racism
School Issues
Self Esteem
Self-Harming
Serious Mental Illness
Sex Therapy
Sexual Abuse
Spirituality
Substance Misuse
Suicidal Ideation
Trauma and PTSD
Women's Issues

ADHD
Anger Management
Anxiety
Bipolar Disorder
Coping Skills
Couples Counseling
Depression
Domestic Violence
Eating Disorder
Family Conflict
Family Therapy
Grief
Insomnia/Sleep Issues
Learning Disability
Life Transitions
Men's Issue
Mood Disorder
Obsessive-Compulsive (OCD)
Older Adults
Parenting
Peer Relationships
Personality Disorder
Phobia
Post Partum
PTSD
School Issues
Self Esteem
Self-Harming
Sex Therapy
Sexual Abuse
Sexuality Issues
Spirituality
Suicidal Ideation
Trauma
Women's Issues