Alabama Patient Information and Consent

First Name

Last Name

Email

Phone #

How can we help you?

Therapy

Medication Management

Street Address

City

Zip Code

State

Date of Birth (MM/DD/YYYY)

Social Security #

Gender

Male

Female

The main problem that brings me to clinic is

Please provide us with your pharmacy's phone number

Is the patient a child or minor?

Yes

No

Fathers Name

School Name

Mothers Name

School Phone #

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Do you have any other medical conditions?

Could you be pregnant (women in childbearing years)?

Yes

No

Have you ever had previous experience with psychiatry, counselling, or therapy?

Yes

No

Was the care you received helpful?

Yes

No

Was your treatment experience negative in any way?

Yes

No

Have you ever sought or received treatment for any mood issues?

Yes

No

Do you smoke, or have in the past?

Yes

No

Do you drink alcohol, or have in the past?

Yes

No

Do you currently, or have in the past, used any "street drugs"?

Yes

No

List all prescription and non-prescription medications you currently take

Please separate each medication to one per line.

What medications are you allergic or have had bad reactions?

NOTE: The following links contain very important information regarding your care, your rights and responsibilities as a patient. Please read these documents before signing.

I, have read and agree to the Informed Consent For Assessment And Treatment

I, have read and agree to the Telehealth Services Informed Consent

I, have read and agree to the Notice Of Privacy Practices

I, have read and agree to the Alabama Private Pay Acknowledgement

Please upload a picture of an identification card (eg Driver's license, , Passport, etc)

Select or take picture

Please upload a picture of yourself (we need this to verify your identity)

Select or take picture

Please draw your signature below

Sign Here