Name * First Name Last Name Date of Birth * Gender * Pronouns Phone * Email * (###) ### #### Emergency Contact * relationship/phone number Address 1 Address 2 City State/Province Zip/Postal Code Country * Option 1 Option 2 Insurance Card Information * Health insurance information How Did You Find Out About Us Presenting Concerns * What are your main reasons for seeking care at this time? When did the concerns begin and how are the affecting you? Current medication/s Have you ever been hospitalized for mental health reasons? If Yes, please provide details: Allergies * Consent: By signing below, you acknowledge that the information provided is accurate to the best of your knowledge and consent to treatment as discussed with your provider. * Sign and Date Thank you!