Discovery Form

Discovery Form
If this an emergency, DO NOT use this form and call 911 instead.

Data from this HIPAA compliant form is not monitored in real-time, and filling out this form does not create a patient-provider relationship.
Demographics
Legal Name (Name on your ID and/or Insurance Cards)

First NameLast Name
Preferred Name (If different than legal name)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender Identity
Pronouns
Sex Assigned At Birth
This helps us provide medically appropriate care and screenings)
Sexual Orientation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Carrier
Name of primary insured person
Insurance ID Number
Insurance ID (Front)

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Insurance ID (Back)

Cancelof

Care Requested and Current Care Team
How did you hear about us?
If you are being referred by a provider please list their name.
What Treatment(s) are you seeking?

Other
Primary Care Provider
If you dont have a primary care provider, type "None"
Psychiatric Provider (The person prescribing psychiatric medications to you, typically MD, DO, APRN, etc.)
If you dont have a psychiatric provider, type "None"
Psychotherapy Provider (The person providing "talk therapy" to you, typically PhD, PsyD, LCSW, MD, etc.)
If you dont have a therapy provider, type "None"
Other Notable Care Providers
E.g. if you are under the care of a specialist for a chronic condition please list them here.

Psychiatric Presentation & Basic History
At what age did you first experience mental health symptoms?
What were the symptoms?
At what age did you first diagnosed by a mental health professional as having a mental health diagnosis? What was the diagnosis?
What are the psychiatric diagnos(es) given to you?
What are the psychiatric diagnos(es) you believe you have?
If no difference than the previous question, can simply write "the same"
When was the last time you felt mostly well for a 2 month period?
What symptoms are bothering you the most? How long have they been bothering you?
Have you had symptoms like this in the past?
Are you taking psychiatric medications? if so please list them here
Please include the medication name and dosage. Only list medications you are currently taking here.

Psychiatric History
Has a mental health professional ever recommended any of the following treatments for you?
Have you ever been psychiatrically hospitalized? If so, please list them below with dates and details of each hospitalization
Please try to be as detailed as possible, but exact dates are not necessary
Have you ever utilized other higher levels of mental health care? This includes PHP, IOP, Residential programs etc. If so, please list them below with dates and details
Please try to be as detailed as possible, but exact dates are not necessary
Please list the medications you have tried in the past?
Please try to be as detailed as possible, but if you dont remember the exact doses or dates please provide your best estimate

Medical & Social History
Do you have a history of, or ongoing major medical illnesses?
This can include major surgeries, chronic illnesses or life-threatening medical events
Do you have a history of, or ongoing major social factors or life events affecting your mental health?
This can include major life stressors, trauma or other events affecting your life and mental health
What do you do for a living? (e.g. Student, Job(s), freelance work, etc.)
If you are a student please provide details; if you are not currently working please provide your main source(s) of financial support.
Do you currently use any substances (including nicotine, alcohol, THC products)?
If yes, provide frequency, amounts and for how long you have used each substance
Do you have a history of using any substances (including nicotine, alcohol, THC products)?
If yes, provide frequency and amounts used and the timeline of when it was started and when it was stopped

Demographics