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Please upload divorce decree or child custody paperwork
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Social history
Tell us if you live with parent(s) and/or family. Also about your support group(s), work, school, pet(s) and social activities.
Family history
Tell us about any history of mental illness in your parent(s), grandparent(s), sibling(s) and relatives.
List and describe any past hospitalization(s)
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Are you requesting this appointment for any legal issues such as child custody, disability, job clearances, or workman's comp related matters?
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Please take back photo of your insurance card like the example below.

Use landscape orientation and ensure your insurance card photo is clear readable.