NEW PATIENT INFORMATION AND FORMS TO COMPLETE PLEASE TYPE YOU ANSWERS First and Last name * (###) ### #### Phone number * Address * Email address * Relationship status (single, married, divorce, etc) * Who lives with you? (spouse, children, friends, pets) * Children if any * Education (high school, college, university, etc) ) * Occupation, if working * Who is your primary care provider , if any? Are you treated for any chronic conditions? * Are you under care of specialist? (cardiology, neurology etc.) * Do you have medication allergies? Seasonal allergies? Food allergies? If any describe * Have you had any surgeries * Medications prescribed for medical conditions by primary care doctor or specialists, not mental health, if any * Past Psychiatric History (if any) * Current Psychotropic Medications (if any) * Past Psychiatrists (if any) Have you ever been in therapy? * if yes, are you currently in therapy? Who is your therapist? Past hospitalisations related to mental illness * Do you use any substances not prescribed ? * For example, TSH, marijuana, opioids, benzos, sedatives, street drugs, etc. Alcohol use * if so how often, how much? Do you smoke cigarettes? Vaping? *
