New Client Questionnaire

All information submitted is confidential and secured via HIPAA compliant encryption.

Please briefly explain your reason for seeking treatment

Are you interested in:

Psychiatric Evaluation Medication Management Psychotherapy ADHD Testing Genetic Testing for guiding medication choices

How did you hear about this practice/Who were you referred by?

Are you currently under the care of a psychiatric provider?

Yes No

Do you have any prior psychiatric diagnosis?

Yes No

Are you currently taking any psychiatric medications?

Yes No

Have you had any psychiatric hospitalizations in the past several years? Please include any residential programs and/or IOPs.

Yes No

In the past several years, have you had any suicide attempts, self-harm, thoughts of suicide or of harming yourself/others?

Yes No

Have you had or currently have any substance abuse? Please briefly explain any substance use issues.

Phone

WellBeing NP offers virtual mental health care and natural supplements, making emotional wellness easy, holistic, and accessible.