MindSpa Psychiatry & Therapy - New Patient Intake Form

Adult Psychiatry & Telemedicine located in the following locations in Florida: Delray Beach, Lake Worth, West Palm Beach, Boca Raton, Royal Palm Beach and Wellington

Step

Let's start with your first and last name

What is your email address?

What is your phone number?

What is your date of birth?

Gender

What services are you looking for?

Insurance

ID number

Group number

Picture of front and back of insurance card and photo ID

Upload .jpeg, .png, or .pdf files

Reason for being seen? (optional)

How did you hear about us? (optional)

Have you seen a psych provider in the past?

Do you have a therapist?

Past psychiatric diagnoses?

Any substance/alcohol abuse history?

Any recent psychiatric hospitalizations?

Any current suicidal thoughts?

Current psychiatric medications?

Current medical or over-the-counter medications?

Past medical diagnoses?

Do you have a history of seizures or neurological conditions?

Allergies to medications?

What pharmacy would you like to use? (Name and address)

Height

Weight

Current home address?

I have read and agreed to the Privacy Policy and Terms of Use, and I confirm that I am at least 18 years old and have the authority to make this appointment.

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I agree to receive text messages from this practice and understand that message frequency and data rates may apply.

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