Assessment Form

Who is this assessment for?

For myself Adult, 18 years or older

For my child or teen Under 18 years old

Contact information

If this assessment is for a child or teen, provide the parent or guardian's contact information here.

First name *

Last name *

Email address *

Phone number *

Date of birth *

Street Address *

City *

State *

Zip Code *

Child or teen's information

Complete this section only if the assessment is for someone other than yourself.

Child's first name

Child's last name

Child's date of birth

Your relationship to the child

Insurance

Do you have insurance? *

Yes, I have insurance

No, I will self-pay

We accept Cigna, Blue Cross Blue Shield, Aetna, United Health, and Optum. If you're unsure about coverage, contact us before your visit.

Insurance provider

Member ID

Group number (optional)

Policyholder name (if different from patient)

Your concerns

Previous care

Have you received psychiatric or mental health care before? *

Yes

No

Current or past mental health provider (optional)

Date of last visit (optional)

If yes, briefly describe prior treatment (optional)

Have you ever been hospitalized for a psychiatric illness?

Yes

No

Current medications (optional)

List any psychiatric or other medications you are currently taking, including dosage if known.

Anything else we should know? (optional)

Referral source *

Consent & acknowledgment *

I agree to receive tele-health services and understand I will be contacted once an opening becomes available. Completion of this form is not a guarantee of services. Referrals from hospitals and primary care clinics are prioritized.

If you need immediate psychiatric care, do not submit this form. Seek emergency care or call 911.

Your information is private and will only be used to prepare for your appointment. Fields marked are required.

We'll follow up by phone or email to confirm your appointment.

Who is this assessment for?

Contact information

Insurance

Your concerns

Previous care

Not sure how to describe what’s been going on?