New Patient Info – Mental Health Care Guide

Patient Intake Questionnaire

Form Submitted Successfully!

Thank you for submitting the forms. We have received your details and will reach out soon.

Patient Intake Questionnaire

Thank you for reaching out. Please fill out the following details to help us schedule your appointment.

Please Note: Solutions for Mindfulness currently provides services exclusively through secure telehealth appointments. All consultations are conducted remotely.

Who is completing this form?

Are you filling this form for yourself or on behalf of someone else? *

Myself On behalf of someone else

Patient full Name: * Gender: * Contact Number: * Email: Date of Birth: * Street Address: * City: * State: Zip Code: * Where did you hear about us from * Are you currently receiving mental health services? If Yes, please explain: Do you have a therapist? Are you currently taking psychiatric medications? If so, list the medication and dose: Do you suffer from depression, anxiety, substance abuse, or alcohol abuse? Please specify: Do you have any other medical problems? (HTN, diabetes, thyroid problems, etc.): Reason for Referral:

Insurance Information

Do you have insurance?

Form Submitted Successfully!

Patient Intake Questionnaire

Insurance Information

Open Hours