New patient questionnaire

Please take a moment to tell us more about yourself. These answers will be reviewed only by Dr. Sotelo and submitted to a secure, encrypted service.

Please Confirm *

I am not currently in a crisis. If you are currently in a crisis, please call 911, go to the nearest ER, or call the 988 crisis line.

Your Contact

Full Name *

Date of birth *

Email *

Phone *

Your health and interests

How can I help you? *

Which of these describes your situation best? Select all that apply:

Interested in Medication Management

Currently on medication for a mental health issue

Took medicine in the past, but none now

Attempted suicide in the past

In the hospital within the past year for a mental health issue

In therapy in the past

In therapy currently

Interested in talk therapy

Interested in nutritional/lifestyle approach to my symptoms

Please list all current medications: psychiatric, medical, over the counter vitamins, supplements, including medical marijuana

Terms and conditions

I understand that completing this form does not establish a physician-patient relationship.

And, I understand that it may take several days for my request to be processed. If you have not received any communication within 1 week, please call the office at 512-882-4552

I consent to receive text messages, voicemail, or email regarding your request.