Date of birth *
Gender *
Insurance company name *
ID number *
Group number *
Insurance subscriber name *
Insurance subscriber relationship to you *
Insurance subscriber date of birth *
Phone number *
Email *
Street address *
City *
State *
Zip code *
Secondary insurance company name (optional)
Secondary insurance ID number (optional)
Secondary group number (optional)
Reason you are seeking mental health treatment. *
Psychiatric medications you are currently taking or were recently taking. *
Do you have any legal issues? *
Have you ever been accused, charged, arrested, and/or convicted of crimes against children ? *
Have you ever been accused, charged, arrested, and/or convicted of any sexually related crimes? *
number company issues?
Do you have any recent history of alcohol or substance use ? *
Do you have suicidal or homicidal thoughts or urges? *
Are you currently prescribed or interested in controlled substances such as benzodiazepines (such as Xanax, Klonopin) , stimulants (such as Adderall, Vyvanse, Concerta, Ritalin), or hypnotics/sleeping medications (such as Ambien or Lunesta). *
Do you regularly use any illicit substances or take medication not prescribed to you ? If so, please specify. (Examples: alcohol, cannabis, cocaine, heroin, opiates, methamphetamines, Kratom, benzos, stimulants) *
How did you hear about Healing Minds Psychiatry and Mental Wellness, LLC? *
Are you ok with telehealth appts ? *
