Elizabeth May, MD | Psychiatry & Psychotherapy

Home Approach Services FAQ Contact

Patient Intake Form

I will respond to new patient inquiries within 2-3 business days.

If you are having a medical or psychiatric emergency, call 911 or go to your nearest emergency room.

Name

First Name

Last Name

Pronouns

Date of Birth

YYYY

Are you >18 yrs of age?

Yes

Email:

Phone:

(###)

###

####

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What brings you here (reason for seeking treatment services)?

Please describe any history of prior treatment (medications, therapy, etc):

Please give a brief history of presenting clinical issue, from onset to present:

Have you received any mental health diagnoses in the past? If yes, please list:

Have you ever been hospitalized or seen in the ER for your mental health?

If yes, please elaborate in space provided:

Do you own a firearm?

Yes

Please describe any medical problems for which you see a doctor/specialist:

Do you have any allergies (please indicate reaction - for example, hives, etc)?

Please provide the name/contact information for your primary care physician:

Please list current medications (including dose, frequency):

Do you have insurance?

Yes

Insurance company:

Emergency Contact:

First Name

Last Name

Emergency Contact Phone:

(###)

###

####

Anything else you feel is particularly important to share prior to scheduling introductory 15 minute phonecall?

Elizabeth May, MD | Psychiatry & Psychotherapy

Patient Intake Form

Elizabeth May, M.D. | 802.300.3605