All Well Health | SimplePractice

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Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

Reason for care

Previous Diagnoses (Select all that apply):

ADHD Anxiety Autism Developmental Disability Other None

Which best describes the service(s) you require?

Psychiatric Assessment and Medication Managment Therapy Executive Function Coaching Other

Which of the following options are you interesting in learning more about? *

Select all that apply.

Diagnostic evaluation (to determine if you meet criteria for a diagnosis) Medication management Individual Therapy Family Therapy Couples Therapy Executive Function Coaching/ADHD Coaching Parenting Support Accommodation Documentation (for school, standardized testing, or workplace) Not sure yet / would like guidance Other

In the last year have you or the person you're inquiring about experienced any of the following? (select all that apply)

Emergency room visit or hospitalization for suicidality or other mental health reasons Residential treatment or wilderness program Intensive outpatient program (IOP) or Partial Hospitalization program (PHP) None of the above

Do you have a eating disorder that restricts or limits that you intake?

If yes, please explain

Administrative

Referral source

Enter how you were referred to our services

I am completing this for (select all that apply):

Myself My child (minor- 17 or younger) My child (adult- 18 or older) Partner/spouse Other

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.