What is the name and age of the person seeking care?
Please choose the state in which you are requesting treatment:
Any history of schizophrenia, schizoaffective, any diagnosis with psychotic features and/or ever
experienced an episode of psychosis?
Have you ever been involuntarily committed to an inpatient unit for psychiatric crisis or have any
history of suicide attempts?
Are you seeking care for the purpose of establishing disability, custody, or other court related
Are you dealing with any legal issues at this time, or in the past?
Have you received psychiatric care before?
Why are you seeking care now? Check appropriate answers below:
Are you taking any psychiatric medication?
Please list ALL current psychiatric medication
Please list all previous psychiatric meds
Are you taking any other medication?
Please list ALL other medication you currently take and the reason you take it
Is there any additional information you would like us to know so we may better assist you?
Please enter your email and phone number.