Tailored Psychiatric Wellness New Patient Intake

About you

Tell us who you are and how to reach you. If you are completing this for a child or someone in your care, enter the patient’s details here.

Some medications are dosed differently, so this helps your provider.

Contacts & pharmacy

Who we can call in an emergency, and where your prescriptions should go.

e.g. Walgreens on Main St

Insurance & payment

Please do not enter card numbers here. The office will collect payment details securely.

How will you be paying?

Health history

This helps your provider prepare for your first visit. Share what you are comfortable with. You can go over the details in your appointment.

Have you seen a psychiatrist, therapist, or counselor before?

Have you ever been hospitalized for mental health?

Are you currently taking any medications or supplements?

Do you have any medication allergies?

Do you use cannabis or any other substances?

In the past month, have you had thoughts of harming yourself or someone else?

Treatment & telehealth

Read each statement, tick the box, and type your initials once for each section.

Consent to Treatment

Telehealth Consent

The practice may contact me by (tick all that apply)

Emergencies & appointments

Read each statement, tick the box, and type your initials once for each section.

Emergency & Limitations of Care

Appointment & No-Show Policy

Financial & AI-assisted care

Read each statement, tick the box, and type your initials once for each section.

Financial Policy

AI-Assisted Care Consent

Review & sign

Check your answers below. Use “Edit” to change anything, then sign to submit.

Who is signing this form?

Typing your name here is your electronic signature.

Electronic signature agreement

Thank you, your intake is complete

We have received your forms. Your next step is to book your first session.

Book an appointment

Reference:

If you are having a medical or mental health emergency, call 911 or go to the nearest emergency room. You can also call or text 988 (Suicide & Crisis Lifeline) at any time.

Your information is sent securely and is only used by Tailored Psychiatric Wellness Center for your care.