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New Patient screening form
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Email
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Your email
First Name
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Your answer
Last Name
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Phone number
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Your answer
Date of birth
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Preferred name
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Personal pronouns
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Insurance Company (please note, we are not able to accept medical assistance or medicare plans)
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Insurance member ID
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What led to the decision to request an evaluation?
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What has been your experience with medication or therapy?
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Do you have a therapist? If so, please give name and how long you have been seeing them.
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Current medications and doses
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Do you have any accessibility needs?
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In my practice I do not prescribe stimulants (adderall, ritalin, concerta, vyvanse, or other similar medications used to treat ADHD) and I do not prescribe high doses of benzodiazepines (klonopin, xanax, ativan, valium, etc). I do not prescribe xanax, except for rare exceptions and for a very short time.
Have you read and understood the practice policies regarding stimulants and benzodiazepines?
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