SELF SCREENING TOOL FOR NEW PATIENTS

Thank you for your interest in Integrative Psychiatry Austin. In order to determine whether we are a good fit for your mental health needs, please answer the following questions in order to receive a New Patient Information packet. Included in this packet will be instructions on making your first appointment.

First Name (if you are looking for help for a minor please fill the minor's name) *

Last Name *

Date of Birth (if you are looking for help for a minor please fill the minor's date of birth) *

Pronouns *

Email Address *

Postal Code *

Phone Number *

What is the problem or goal for which you’re seeking guidance? *

Have you ever been hospitalized for a mental health diagnosis? *

Have you had any serious suicidal thoughts in the last 3 years? *

If you answered "Yes" to the above, please provide details. If you answered "No" then put "N/A" *

Are you looking for a consult or establish long term care? *

Who referred you to us?

Our clinic has a unique advantage of having multidisciplinary team assessments. indicate the assessments. Please select the assessments you are interested in: *

Medication management

Herbal medicine

Functional medicine

Nutritional medicine

Neuropsychological and Academic testing

Psychotherapy

Ketamine Assisted Therapy

Health and wellbeing coaching

I am open to suggestions

Who would you like to see? (Feel free to leave blank if you don't know)

We can provide multidisciplinary assessments online as well. Are you interested in seeking care: *

Online

In-person

Sometimes online and sometimes in person

If the patient is a child, are parents separated or divorced? If yes, then both parents must complete consent forms unless we receive legal documentation of a parent's right to independently consent to their child's mental health treatment. *

Yes

Not applicable

Please provide us additional details on the situation that brings you in for guidance, if medication management is involved please provide current medication and dosage. Please note that our practice does not prescribe benzodiazepines. Is there anything else about your mental health needs that you want us to know? *

Please check this box giving us permission to email or text you to help coordinate your care. *

Yes

Please note that Blossom does not provide behavioral health crisis services. If you are experiencing a crisis, please contact 911 for help.

WE RESPECT YOUR PRIVACY