If you are filling this out for an adult please skip the red boxes Patient Name Patient Age E-mail Address Phone Number What insurance do you have? Current Medications The parents of the child are? The parents of the child are?MerriedDivorcedNever-Merried Which parent has medical decision making? Do both parents consent to this child being by a Psychiatrist? Are there any legal procedings involving the new patient? Is there a history of drug use/abuse? Please list the reason/s that we will be seeing the patient (anxiety, depression, eating disorder, etc...) and any additional information. 12 + 11 = Submit