Patient Pre-Screen & Telepsychiatry Suitability

Patient Pre-Screen & Telepsychiatry Suitability

Before we schedule your first appointment, please take a moment to answer the following: Your responses help us understand your needs and ensure telepsychiatry is the right level of care for you.
Patient's First Name
Patient's Last Name
Date of Birth

MonthDayYear
Date
Gender
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address
example@example.com
Insurance Name
Insurance ID
Name of Emergency Contact
Relation with Emergency Contact
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
What mental health concern(s) are you seeking help with?
Are you currently taking any psychiatric medications?
If yes, please list your current psychiatric medications.
Who is currently managing your psychiatric medication?
Have you ever been hospitalized for a mental health reason?
If yes, approximately when was the most recent hospitalization?
In the past year, have you experienced thoughts of suicide or self-harm, or made a suicide attempt?
Do you currently experience hearing voices, seeing things others don't, or holding beliefs that others strongly question?
Have you used methamphetamine, cocaine, heroin, fentanyl, or other non-prescribed substances in the past year?
When would be the best time to reach you to schedule your appointment?
Should be Empty: