Accepting new patientsTexas residents onlyWe do not accept MedicaidNow open: North Dallas office
Online patient form

New Patient Questionnaire

Fields marked * are required. Your answers are sent securely to our intake team — nothing is stored in your browser.

How did you hear about our clinic?
Personal Details
Race
Ethnicity
Marital Status
Smoking Status
Primary Contact Details
Primary Phone
Emergency Contact
Allergies
Supplements

History of Present Illness

Depressive Symptoms

Depressive symptoms
Depressive symptoms — if reported, select all that apply
Sleep
Appetite
Weight
Suicidal Ideation
If you are thinking about harming yourself, call or text 988 (Suicide & Crisis Lifeline) or call 911 now — this form is not monitored in real time.
Homicidal ideation

Manic Symptoms

Manic symptoms
Manic symptoms — if reported, select all that apply
Destructive impulsivity

Psychotic Symptoms

Psychotic symptoms
Psychotic symptoms — if reported, select all that apply

Obsessive-Compulsive symptoms

Obsessive-compulsive symptoms
Obsessive-compulsive symptoms — if reported, select all that apply

Attentional/Hyperactive/Impulsive Symptoms

Attentional/hyperactive/impulsive symptoms
INATTENTION
HYPERACTIVITY
IMPULSIVITY

Panic Symptoms

Panic symptoms
Panic symptoms — if reported, select all that apply

Generalized Anxiety Symptoms

Generalized anxiety symptoms
Generalized anxiety symptoms — if reported, select all that apply

Post Traumatic Symptoms

Post traumatic symptoms
Post traumatic symptoms — if reported, select all that apply

Eating Disorder Symptoms

Past Medical History

Past Psychiatric History?
Past Medical History?
Past Medications: Please list ALL medications you have been on in the past
Current Medications: Please list ALL current medications
H/O Head Injury or Seizures or TBI?
Allergies?

Family History

Family History?

Social History

Tobacco
Alcohol
Substances, Other
Abuse and Trauma
Current Living Arrangements

Your submission is emailed securely to our intake team. This form is not for emergencies.

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