Potential New Patients

For potential new clients, please complete this secure and confidential online form to start the intake process. Below is an example of the information I ask for you to provide me in order to determine if we will be a good fit to work together.

General Information:

  1. What is your cell phone number and email?
  2. How old are you (if you are an adult or teen seeking treatment), or how old is your child (if you are a parent)?
  3. What is your name (and your child/teen’s name)?
  4. Who referred you?
  5. Where do you live? (Or where does your child/teen live?)
  6. How interested or not interested are you (or your child/teen) in receiving treatment in general?
  7. Are you looking for therapy, medications, nutritional supplements, combination therapy and medication, unsure, or something else?
  8. If you are interested in medications would you be interested in therapy as well?
  9. Are you able to come in for weekly, biweekly or monthly sessions?
  10. Please provide a brief summary of what has been going on and what are your goals for treatment?


Past or current mental health treatment:

  1. Are you (or your child/teen) currently in treatment with a therapist or psychiatrist? For how long? What do you like or not like about this treatment?
  2. What types of treatment have you previously tried? With a therapist or psychiatrist? What was helpful or not helpful?
  3. What diagnoses have you (or your child/teen) received?
  4. If you (or your child/teen) is currently on psychiatric medication what medications and doses are prescribed? What are the effects? How long have you been taking these?
  5. What past medication has been tried? What doses, duration of use and effects?
  6. Have you (or your child/teen) had any past treatment in a psychiatric inpatient treatment facilities? How many times? Where and when was this? How long was the hospitalization?


Substance Use

  1. How much are alcohol, recreational or prescription drugs part of the picture?
  2. Do you have any concerns for your (or your child/teen’s) current or past substance use? Or do others share their concerns for your current or past use?
  3. What substances are you (or your teen/child) currently using and how much?


Safety Concerns

  1. Any history of suicide attempts? How many? When was the first or last time? What was tried? Did this require hospitalization (medical and/or psychiatric)?
  2. Any history of self injurious behaviors (such as cutting)? How long has this been going on? When did this start and when was the last time?
  3. Is this a current or past concern?


Family Involvement

  1. If your child/teen is under 18 and if the parents are divorced, does the other parent have any legal or physical custody?
  2. If so, how open or not open is that parent to coming in during the assessment and/or potentially being involved in ongoing treatment?


Contact me today to start the conversation.