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 MM DD YYYY Are you >18 yrs of age? Yes No 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? Yes No I'm not sure If yes, please elaborate in space provided: Do you own a firearm? Yes No 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 No 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? Thank you!