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Do you have any allergies?

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.

Illness	Father	Mother	Aunt	Uncle	Brother	Sister	Children	Children
adhd/add
alzheimer's
anxiety
bipolar
depression
heart disease
schizophrenia
seizures
stroke
substance abuse
suicide attempts

List and describe any past hospitalization(s)

Are you currently pregnant or is there a change you could be?

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Is this request for legal matters?

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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What can we help you with today?

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Create profile

Enter verification code

Are you a new patient?

Are you registering yourself or someone else?

Tell us about yourself

Tell us about your dependent

Tell us about yourself

Please upload divorce decree or child custody paperwork

Upload government issued ID

Would you like to add your health insurance?

Self Pay

Select insurance provider

Upload your insurance card

If prescribed, would you like your medications to be shipped to you?

Select your local pharmacy

Enter current medication(s)

Do you have any allergies?

Social history

Family history

List and describe any past hospitalization(s)

How frequency do you consume alcohol?

How frequency do you smoke?

Are you currently pregnant or is there a change you could be?

Is this request for legal matters?

Explain your legal matter

What can we help you with today?

How did you hear about us?

Terms & Conditions

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Registration complete