New Patient Screening Questionnaire

Telehealth Pre-Screening and Eligibility Questionnaire (For New Patient Requests - Not for Emergencies)

Complete this form to determine if our practice is an appropriate fit for your needs. This is for non-emergency screening only.
This form is for non-emergency screening only to see if our practice is an appropriate fit. Completing this form does not establish a patient–provider relationship or guarantee that you will be scheduled for an appointment. If you are experiencing a mental health emergency, including thoughts of harming yourself or others:
- Call 911 or go to the nearest emergency room.
- Call or text 988 (Suicide & Crisis Lifeline).
- Do not wait for a response to this form.
SECTION 1 – Basic Information
Legal First Name*
Legal Last Name*
Date of Birth (MM/DD/YYYY)*

MonthDayYear
Date
Age*
Best Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
City*
State*
Myself (age 18 or older)My child (under 18)
How did you hear about Resonance Psychiatry?
SECTION 2 – Location and Telehealth Eligibility
Resonance Psychiatry primarily provides care by secure video. At this time we can generally treat patients who are physically located in New Jersey, Massachusetts, Florida, or Vermont at the time of each visit.
In which state do you live most of the time?*
Please specify your state of residence:*
At the time of most appointments, in which state do you expect to be physically located?*
Please specify the state you expect to be physically located in:*
YesNo
Based on your answers, our practice may not be able to provide care. We recommend contacting your insurance or local mental health providers for in-person resources.
SECTION 3 – Presenting Concerns and Fit With Practice
This section is to see whether your needs are a good fit for a small, telehealth-focused psychiatric medication practice.
Briefly, what are the main concerns you are seeking help with right now? (1-3 sentences)*
Anxiety, worry, panicDepression, low mood, or loss of interestTrauma or PTSD symptomsAttention / concentration problems / possible ADHDMood swings or possible bipolar disorderPregnancy, postpartum, or perinatal mental healthStress related to school, work, or life transitionsMedication management for existing diagnosesSecond opinion about current psychiatric medicationsOther (briefly describe)
If Other: Please briefly describe
Active eating disorder (e.g., restricting, bingeing, purging, or frequent loss of control over eating)Primary substance or alcohol use concerns (e.g., dependence, needing detox, daily heavy use)Primary personality disorder treatment (for example, intensive treatment for borderline, antisocial, or narcissistic personality disorder)Court-ordered evaluation or treatmentForensic or disability evaluations (e.g., for legal cases, court, child custody, or disability claims)None of the above
Based on the information provided, your current needs may be better served by a different type of provider or higher level of care. Resonance Psychiatry is not able to provide the specialized or intensive treatment required for these conditions.
SECTION 4 – Safety / Level of Care Screen
NoYes – occasional thoughts, but no plan or intentYes – with a specific plan or intent
NoYes – thoughts only, no plan or intentYes – with a specific plan or intent
Been hospitalized on a psychiatric unitGone to an emergency room for a mental health or substance-related crisisNeither of the above
YesNoNot sure
Based on your answers, you may need a higher level of care or more intensive, in-person support than our telehealth practice can safely provide. Please call 911 or go to the nearest emergency room for immediate help. Call or text 988, the suicide and crisis lifeline. Contact local crisis services or your primary care provider to discuss urgent options.
SECTION 5 – Substance Use and Eating Disorder Quick Screen
NoYes – occasional / social useYes – I use daily or almost daily, or I am concerned I may be dependent
YesNo
YesNo
Restricting food intake / significant weight lossFrequent binge-eating episodesSelf-induced vomiting, laxative misuse, or other purging behaviorsMedical complications related to weight or nutritionNone of the above
Based on your answers, you may need a higher level of care or a specialized provider for substance use or eating disorders. We recommend contacting local resources or your primary care provider for appropriate support and referrals.
SECTION 6 – Prior Diagnosis / Treatment Snapshot
NoYes
DepressionAnxiety or panic disorderBipolar disorderPTSD or trauma-related disorderADHDOCDEating disorder (anorexia, bulimia, binge eating, ARFID, etc.)Substance use disorder (alcohol or drugs)Personality disorder (e.g., borderline, antisocial, narcissistic, avoidant)Psychotic disorder (e.g., schizophrenia, schizoaffective)Other (please specify)
NoYes – with an individual therapistYes – in a higher level of care (IOP, PHP, residential, etc.)
SECTION 7 – Medications and Prescribing Expectations
YesNo
NoYes – prescribed by a current providerYes – but not currently prescribed / getting them from other sources
Starting ADHD medications (stimulants)Continuing ADHD medications (stimulants)Starting or continuing benzodiazepines for anxiety or sleepStarting or continuing opioid medication for painGeneral medication evaluation / management (not focused only on controlled substances)
Please read and confirm your understanding:
Resonance Psychiatry may prescribe stimulants and, in very limited cases, benzodiazepines, but prescribing controlled substances is not guaranteed, even if you have received them in the past.
Prescribing decisions are based on a full clinical evaluation, safety considerations, and legal requirements.
Some medications (including certain controlled substances) may be better managed by in-person providers or specialty programs.
YesNo
Based on your expectations regarding controlled medications, our practice may not be the best fit for your needs.
SECTION 8 – Next Steps, Consent for Contact, and Certification
YesNo / Not sure
Is there anything else you would like us to know when reviewing your request?
Certification and Permission to Contact
I understand and agree
I certify
I give permission
YesNo
Insurance Information

Please provide your insurance details below.
Insurance Provider Name*
Policy Number*
Group Number
Relationship to Insured
Name of Primary Insured

First NameLast Name
DOB

MonthDayYear
Date
Should be Empty:

Telehealth Pre-Screening and Eligibility Questionnaire (For New Patient Requests - Not for Emergencies)

SECTION 1 – Basic Information

SECTION 2 – Location and Telehealth Eligibility

SECTION 3 – Presenting Concerns and Fit With Practice

SECTION 4 – Safety / Level of Care Screen

SECTION 5 – Substance Use and Eating Disorder Quick Screen

SECTION 6 – Prior Diagnosis / Treatment Snapshot

SECTION 7 – Medications and Prescribing Expectations

SECTION 8 – Next Steps, Consent for Contact, and Certification

Certification and Permission to Contact

Insurance Information