• Psychiatry Clinic New Patient Form

  • Peace be upon you!

    Thank you for your interest in Al-Shifa Free Psychiatric Clinic. Before completing this application, please note:

    • All appointments are conducted by telehealth. We do not offer in-person appointments.
    • You MUST reside in MN at the time of your appointment.
    • Our services are free and intended for people who do not have health insurance or who have insurance but cannot afford the cost of psychiatric care.
    • Submitting an application does not guarantee acceptance. Our clinical team reviews every application to determine whether our clinic is appropriate for the patient’s needs.
    • You will receive a response regarding your application within one week of submission.
    • We limit access to the information you provide to the staff and clinicians involved in reviewing your application and providing care.

    If you have questions, please email psyclinic@alshifamn.org or visit alshifamn.org.

     

    This application is not monitored continuously and is not an emergency service. If you or someone else may be in immediate danger, call 911 or go to the nearest emergency department. If you are experiencing a suicidal crisis or emotional distress, call 988 or text 988.

  • I am:*

  • Safety Questions

  • Are you currently having thoughts of killing yourself right now?*
  • Are you currently harming yourself or having urges to harm yourself?*
  • Are you currently having thoughts of seriously harming or killing another person right now?*

  • Immediate In-Person Evaluation Is Needed

    Your response indicates a current safety concern requiring immediate, in-person evaluation. Al-Shifa Clinic PA provides non-emergency outpatient telehealth care and cannot provide crisis or emergency services. Therefore, our clinic is not the appropriate level of care for you at this time.

    Please do not continue this application or wait for a response from our clinic. Go to the nearest emergency room now. If you may act on these thoughts, someone else may be in danger, or you cannot travel safely, call 911.

    Anyone, including individuals under 18, can call 988 or text 988 for immediate crisis support. If you are under 18, please also tell a parent, guardian, or another trusted adult as soon as possible.

  • Information About The Person Helping the Patient Complete This Form

    Because you are helping the patient complete this application, please provide your information below.
  • Format: (000) 000-0000.
  • Patient Date of Birth (note: we only accept patients 16+)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient Sex/Gender*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Race/Ethnicity*

  • Unfortunately, because you are NOT located in Minnesota, our Minnesota-based providers are not able to see you.

    Please do NOT move forward with this form, as you are NOT eligible for this clinic.

  • What kind of care is being sought?*

  • NOTE: if you are only requesting psychotherapy, please note that we do not unfortunately have any therapists on our team at this time, though we hope to in the future. Our psychiatrists may be able to provide psychotherapy on a limited basis.

  • Select all of the following that are applicable*
  • Please select which of the following psychiatric conditions you have been formally diagnosed with.*
  • Please list your current psychiatric medications.*
  • Please list any past psychiatric medications.*
  • Do you currently take any non-psychiatric medications?*
  • Please list your current non-psychiatric medications.*
  • Do you have any allergies?*
  • Please list your allergies below.*
  • What is most accurate regarding your smoking status?*
  • Which best describes your alcohol use?*
  • How often do you have a drink containing alcohol?
  • How many standard drinks containing alcohol do you have on a typical day?
  • How often do you have 6 or more drinks on 1 occasion?
  • Do you use recreational drugs?*
  • Are you currently employed?*
  • What is your household income? This is only used for internal demographic data. This information is not reported, nor is it used to decide your eligibility for our clinic.*
  • Please describe your living situation*
  • Including yourself, how many people are in your family household?*
  • Housing Status*
  • Do you currently have health insurance?*
  • Do you consider your insurance to be affordable?*
  • Patient Health Questionnaire (PHQ-9)*
    Rows
  • Generalized Anxiety Disorder (GAD-7)*
    Rows

  • Consent Form

  • I hereby voluntarily consent to receive ongoing medical and/or psychiatric care from Al-Shifa Clinic PA, including examinations, treatments, procedures, laboratory tests, and imaging studies, as deemed necessary by the licensed physicians and healthcare professionals providing care. This consent remains valid for all future visits, unless I choose to revoke it in writing.I understand that Al-Shifa Clinic PA is a volunteer-run clinic providing free healthcare services, and that my care may involve licensed providers as well as student physicians and clinical assistants, all of whom may be supervised by attending physicians. I consent to their involvement in my care as part of the clinic’s educational mission.I understand that no guarantees or promises are being made regarding the outcomes of my care, and that I have had the opportunity to ask questions about this consent and have them answered to my satisfaction.In exchange for receiving treatment and health care services from such volunteers and volunteer health care providers, limitations exist on my ability and right to recover damages against such volunteers and volunteer health care providers.I acknowledge that services provided at Al-Shifa Clinic PA are done on an honorary, volunteer basis, and that this interaction does not establish an ongoing physician-patient relationship. I agree that neither the clinic nor its providers will be held liable beyond the scope of this voluntary encounter. I understand that Al-Shifa Clinic PA does not offer after-hours or emergency care. In case of an emergency, I will seek help at the nearest emergency department or urgent care facility.I also understand that it is my responsibility to follow up with a primary care provider for continued or long-term medical needs. I may continue to return to Al-Shifa Clinic PA for care, as needed and as available.

  • I consent to allow my de-identified health information to be used in future research or quality improvement projects conducted by Al-Shifa Clinic PA, in accordance with applicable privacy laws.*
  • I consent to receiving emails from Al-Shifa Clinic PA for educational and marketing purposes and clinical care updates.*

  • Al-Shifa Clinic PA does not prescribe narcotics or other controlled substances. Examples include ADHD stimulants such as Adderall, Vyvanse, Ritalin, and Concerta; anxiety medications such as Xanax, Klonopin, Ativan, and Valium; controlled sleep medications such as Ambien and Lunesta; Suboxone; and ketamine or Spravato. This list is not exhaustive.

    I understand that Al-Shifa Clinic PA does not prescribe narcotics or controlled substances. I also understand that my provider may discuss non-controlled treatment options or recommend care from another provider when appropriate.

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