If you are filling this out for an adult please skip the red questions. Please enable JavaScript in your browser to complete this form.Name *FirstLastPatient Age *Email *Phone number *What insurance do you have?Current medicationsThe parents of this child are?MarriedDivorcedNever MerriedWhich parent has medical decision making?MotherFatherDo both parents consent to this child being treated by a Psychiatrist?YesNoAre there any legal proceedings involving the new patient? *YesNoIs there a history of drug use/abuse? *YesNoPlease list the reason/s that we will be seeing the new patient, or any additional information. *Submit