Name * First Name Last Name Age * Name of Guardian (if applicable) First Name Last Name Phone * (###) ### #### May we leave a voicemail? Yes No Email * How did you hear about us? Please check all that apply Therapist Referral Psychology Today Insurance Company Primary Care Provider Google/Online Friend or Family Member Chief Concerns or Diagnoses * Please check all that apply Depression Anxiety ADHD Bipolar Disorder PTSD Substance Use Disorder Schizophrenia Other If Other, please provide details. Please list all current and past medications * Please provide any additional pertinent information regarding your appointment request * Please list any medical conditions and significant past medical history below, such as Diabetes, Asthma, Hypertension, etc. * If you have health insurance, please provide the name of your provider I understand that my provider will order blood work, EKG, or vitals, which I agree to completing (unless I have recent results to share). * I agree The submission of this form does not establish a provider-client relationship. After review, we will call you with the available appointment times or to discuss further. Due to the volume of requests, response times will vary. Please check the box below to acknowledge the statement. Thank you. * I agree Thank you! Your form has been submitted. We will contact you after reviewing the information provided. Should you have any questions, please email us at admin@staterabehavioralhealth.com.
