Prospective New Patients To apply for a new patient, please fill out and submit the form below. Person Submitting this form * Email Relationship to potential client * Home Phone Cell Phone PNP Name (If different from submittor) PNP Date of Birth PNP Street Address City State Virginia Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP Code Reason for submission? Referred by? * Risk of cutting? Suicide? Yes No Migraines? Headaches? Yes No Is the PNP requesting suboxone treatment? Yes No If suboxone, what are they using? If suboxone, are there any legal issues? Current medications currently being taken (if applicable) Which antidepressants have been prescribed in the past? Please digitally sign below to signify that: You have been notified that for addiction treatment, we do not accept checks at the first appointment. Office staff cannot guarantee that a specific medication will be prescribed. Requests for specific medications must be made directly to clinical staff. You were notified that if they will be out of medications prior to their appointment with a prescribing staff, they must contact their prior psychiatrist/primary care physician for a refill. If a family member called on behalf of an adult, they were notified that the prospective patient must call to confirm the appointment, otherwise it will be cancelled. You were notified that intake appointments may be cancelled if prior medical/counseling records are not provided before or at the time of the intake appointment. Signature Draw It Type It Clear nine × 6 =