• Mental Health & Medication Management Intake

    Confidential intake — please complete each section accurately.

  • Safety Questions

    In the Past 30 Days

  • Confidential mental health care designed to support your emotional wellness — healing life one day at a time.

    At Simone RX, we understand that mental health care is deeply personal. Our provider-led telehealth experience is designed to provide supportive, compassionate, and convenient access to mental health evaluations, medication management, and ongoing virtual care from the privacy and comfort of your home.

    Whether you are experiencing anxiety, depression, ADHD symptoms, stress, mood concerns, or are seeking continuity of psychiatric medication management, our goal is to help you feel supported throughout your care journey.

    Most intakes take approximately 5–7 minutes.

    ✓ Secure & HIPAA-conscious intake
    ✓ Compassionate provider-led care
    ✓ Medication management & ongoing support
    ✓ Convenient virtual mental health services

  • âš  Important Mental Health Notice — If You Are Experiencing a Mental Health Emergency

    If you are currently experiencing:
    • Thoughts of self-harm
    • Suicidal thoughts
    • Thoughts of harming others
    • Severe emotional distress
    • A mental health crisis

    Please call 911 or seek immediate emergency medical care.

    You may also contact the 988 Suicide & Crisis Lifeline by calling or texting:
    988

    Support is available 24 hours a day, 7 days a week.

  • Basic Information

    Personal Information
  • Format: (000) 000-0000.
  • Thank You for Your Interest

    SimoneRx currently provides telehealth services only to residents of Georgia, California, and New Hampshire.

    Your contact information will be recorded, and our care team will reach out to you as soon as we expand to your state. Please continue to complete this form to join our waitlist.

  • Preferred Communication

    How would you like us to reach you?
  • How would you like us to reach you? (Select all that apply)*

  • Reason for Visit

  • What Type of Care Are You Requesting Today? (Check all that apply)*
  • What Would You Like Support With Today? (Check all that apply)*
  • How Long Have These Concerns Been Affecting You?*

  • PHQ-9 Depression Screening

    Over the past 2 weeks, how often have you experienced the following? All questions are required.
  • Rows
  • PHQ-9 Severity
    0–4: Minimal depression
    5–9: Mild depression
    10–14: Moderate depression
    15–19: Moderately severe depression
    20–27: Severe depression
  • Provider Alert
    PHQ-9 score indicates moderately severe to severe depressive symptoms. Mental health consultation recommended before treatment plan is finalized.
  • If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*
  • Important Support Information

    If you are experiencing thoughts of self-harm, worsening depression, or emotional crisis, please call or text 988 for the Suicide & Crisis Lifeline, or go to the nearest emergency room.

    This form is not monitored for emergencies.
  • Have you had any thoughts of self-harm?*
  • Have you had any thoughts of suicide or suicidal ideation?*
  • Have you been hospitalized for mental health concerns?*
  • Have you used alcohol or substances to cope with emotional distress?*
  • Important Safety Information
    If you answered Yes to questions 1 or 2 and are currently in crisis, please call 911 or contact the 988 Suicide & Crisis Lifeline immediately.

  • GAD-7 Anxiety Screening

    Over the past 2 weeks, how often have you experienced the following? All questions are required.
  • Rows
  • GAD-7 Severity Display

  • Mental Health History

  • Have You Ever Been Diagnosed With Any of the Following? (Check all that apply)
  • Current Mental Health Medications
  • Do You Have Any Medication Allergies?
  • Do you have any medication allergies?*

  • Virtual Visit Preference

    All visits are conducted virtually. Let us know how you would prefer to meet with your provider.
  • How Would You Prefer to Meet With Your Provider?*

  • Upload Documents

    All uploads are optional — you may skip any that do not apply.
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  • Pharmacy Information

    Where would you like us to send any prescriptions?
  • Format: (000) 000-0000.

  • Consent & Acknowledgment

    Please review and check each box to confirm. All are required to continue.
  • Please check ALL boxes to acknowledge and agree*
  • Should be Empty: