Need assistance?
Should you encounter any difficulties while completing this form, please do not hesitate to contact us. We would be pleased to assist you throughout the process.
Description:
This form is intended for adults and parents of minors to provide relevant health information to our care team for the purpose of triaging patients effectively. Age criteria for this clinic is 6-45 years.
Instructions:
Please complete this questionnaire to provide more information about your mental health concerns. This information will help us determine eligibility and fit for this clinic and relevant clinical trials. Please note that this information is being collected on a Health Insurance Portability and Accountability Act (HIPAA)-compliant platform. The questionnaire will be saved to your medical record.
After you complete the form, please expect to hear from our staff within 10 business days. To expedite our intake procedures, please ensure the patient has a Medical Record Number (MRN) and an active Patient Gateway (PG) account. We will provide all subsequent information via PG, so please look out for communications from us, should you decide to fill out the referral form.
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If you need an MRN, contact Patient Registration at (866) 211-6588.
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To enroll in PG, visit Patient Gateway Enrollment or call 1-800-745-9683 for assistance. PG is a secure platform where you can access health information, communicate with our office, pay bills, and more.
Please keep in mind our clinic does not offer the following services:
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Individual or family counseling
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Neuropsychological testing
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Case management services
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Consulting with school staff or IEP/504 recommendations
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Personalized referrals to community organizations
Important note: Some questions on this form may appear or disappear based on your responses.
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