New patient form

Date: *

Name *

First

Last

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? *

psychiatrically Wellness, as

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? *

Do you have any recent history of alcohol or substance use ? *

If so, please specify substance(s) used and frequency of use.

Do you have suicidal or homicidal thoughts or urges? *

If so, are thoughts active or passive ? Please specify in depth. If you are having active suicidal or homicidal ideations with possible intent or plan then please do not complete this form. Call 911 or go to your nearest emergency room.

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). *

If so please specify medication(s), dose and frequency.

Have you been recently psychiatrically hospitalized? *

If so please specify place and dates.

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 ? *

Do you have a provider preference? *

• Laurie Greisch
• Alexandra Ruane
• Either

*Provider preference is taken into consideration, but due to scheduling, it may not be guaranteed.*

Submit

Important Information for New Patient Requests: Thank you for your interest in our practice. Please note that submitting this intake form does not guarantee acceptance as a patient or the scheduling of an appointment. Each request is carefully reviewed by our team to assess fit based on clinical capacity, specialty focus, and other considerations. While we strive to respond whenever possible, please understand that not all submissions will result in follow-up communication, and we may not provide specific reasons for declining a request. We sincerely appreciate your understanding and thank you for considering our practice for your care.