Questions for Intake Appointment

Email(Required)

Full name(Required)

Date of Birth(Required)

Best contact number(Required)

What is your primary reason for seeking treatment? Are there any previous diagnoses?(Required)

When was your first time seeing a psychiatric provider and why?(Required)

Do you have any health problems?(Required)

Are you currently taking medications? If so, please list what medications you are taking and their dosages.(Required)

Are you currently being treated with Methadone, Suboxone, Subutex, or Naltrexone?(Required)

Yes