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Behavioral Health
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e.g. Endocrinology, Dermatology etc.
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Dermatology
Endocrinology
Psychiatry – Medication Management
For Dermatology visits, you're required to upload 2 high res images of the area of concern.*
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Gender at birth*
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Date of birth*
State*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
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Louisiana
Maine
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Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington DC
West Virginia
Wisconsin
Wyoming
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Phone No*
Emergency Contact Relationship
Name of person completing form and relationship to patient*
Reason for appointment*
Current medications and dosage*
List any medical allergies*
Primary Care Physician (Name, Phone, Address)
Preferred Pharmacy
Name
Phone No
Address
City
State
Zip
Appointment type *
Initial consultation visit
Follow-up visit
Is patient a minor ?*
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Do you have any current or pending legal issues or are being advised by a court judge,parole officer, or CPS to seek mental health care or assessment?*
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No
Please select if you have ever experienced or suffered from any of the following in the past or present? (check one or all that applies)
Thoughts of harming others*
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Present
No
Suicide ideation*
Past
Present
No
Alcohol abuse*
Past
Present
No
Substance abuse*
Past
Present
No
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3400 Douglas Blvd.
Suite 225 Roseville, CA 95661
Phone:
(855) 446-8628
Email:
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