Prospective New Patients

Person Submitting this form *

Email

Relationship to potential client *

Home Phone

Cell Phone

Patient Name (If different from submittor)

Patient Date of Birth

Patient Street Address

City

State

ZIP Code

Reason for submission? Referred by? *

Migraines? Headaches?

Yes

No

Are you currently taking:

Marijuana

CBD

Kratom

Is the PNP requesting suboxone treatment?

Yes

No

If suboxone, are there any legal issues?

Current medications currently being taken (if applicable)

Which antidepressants have been prescribed in the past?

If using your health insurance, please select your carrier

Anthem/Blue Cross Blue Shield

Aetna/Innovation Health

Cigna

Please digitally sign below to signify 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.

If you will be out of medications prior to your appointment with a prescribing staff, you must contact your prior psychiatrist/primary care physician for a refill.

Intake appointments may be cancelled if prior medical/counseling records are not provided before or at the time of the intake appointment.

Signature

Clear

Mental Health & Holistic Services

4900 Hood Drive, Fredericksburg, VA, 22408