Patient Self-Referral Form

Patient Self-Referral

Please complete the entire form to request an appointment.

Gender :
Please circle your State of Resident:

Past Psychiatric History (hx) and Treatment (please check appropriately)

Hx of violence?
Hx of suicide attempts?
Hx of psychiatric hospitalizations?
Hx of Substance abuse?
Are you currently in therapy?

Current Psychiatric Treatment & History

Current suicidal / homicidal thoughts?
Do you have a current outpatient mental health provider?

Medical History

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**Please beware WE DO NOT PRESCRIBE BENZODIAZEPINES. There are many safer alternatives to benzodiazepines. For new patients who are already taking benzodiazepines, an individualized weaning plan will be started, and another safer medication will be prescribed to manage anxiety symptoms. **