Clone of 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
Date
Age*
MaleFemaleOther
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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.
AlcoholCaffeineBenzodiazepinesCannabisHallucinogensHypnoticsInhalantsOpioidsStimulantsTobaccoOther
NoYes
Occasionally1–2 times per week3-4 times per weekDailyOther
NoYes
If yes, please specify what recreational drugs or substances.
Occasionally1–2 times per week3-4 times per weekDailyOther
NoneHigh blood pressureDiabetesThyroid disorderSeizuresHeart conditionChronic painHead injurySleep apneaOther
NoYes
If yes, Please describe in detail:
List of Names of ALL current prescribed medications
ProviderTherapistFriendSocial MediaGoogle Search
Name of Referring Provider
Name of Referring Therapist*
Name of Friend*
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
Take Photo (For Patient's Chart)*
Note: Photos uploaded here are for clinic record purposes only and are handled in compliance with HIPAA privacy regulations.
About Our Service

N&I Psychiatry provides medication management and supportive therapy through both in-office and virtual appointments.

We are committed to delivering compassionate, personalized mental health care. Our providers use evidence-based practices to evaluate and treat a wide range of conditions, including depression, anxiety, bipolar disorder, insomnia, PTSD, and other mood-related concerns. We take a holistic approach to treatment, focusing not only on symptoms but also on underlying factors that impact overall well-being.

To learn more about our services, please visit www.nipsychiatry.com or call our office at (904) 394-3232.
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NEW PATIENT REQUEST

N&I Psychiatry