MENTAL HEALTH CARE

Book Your Appointment

Complete your intake form below then select your preferred appointment time. Virtual care from the comfort of your home.

STEP 1 OF 2

Complete Your Intake Form

Please fill out your health information below. All information is kept strictly confidential and secure.

First Name *

Last Name *

Email *

Phone *

Date Of Birth *

State *

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Insurance Provider Name *

Insurance Member ID *

Insurance Group Number

How long have you been experiencing this? *

Less than 1 month

1 to 6 months

6 to 12 months

More than 1 year

Are you currently taking any medications? *

Yes

If yes please list your current medications

Have you seen a mental health provider before? *

Yes

Allergy Information

Any history of substance use? *

Yes

If yes please describeyour substance use history

Provider *

Consent Treatment *

I consent to evaluation and treatment through Complexity Care, including psychiatric evaluation, medication management, treatment planning, and coordination of care as clinically appropriate.

Consent Medication *

I understand that psychiatric medications may carry risks and side effects including nausea, GI upset, headaches, fatigue, insomnia, sexual side effects, emotional blunting, increased anxiety, mood changes, and other possible adverse reactions. I understand that antidepressants carry an FDA black box warning for possible increased suicidal thoughts or behaviors in younger individuals, particularly during medication initiation or dose changes. I agree to notify my provider or seek emergency care immediately if I experience worsening depression, suicidal thoughts, severe mood changes, or thoughts of harming myself or others.

Consent Participation *

I understand that participation in treatment may include recommendations for therapy, behavioral changes, sleep hygiene, exercise, substance reduction, and follow-up appointments, and that no treatment or medication can guarantee results.

Consent Telehealth *

I understand that telehealth and electronic communication including phone, text, email, patient portal, and e-prescribing may involve privacy or technical limitations and are not intended for emergencies. In an emergency I will call 911 or go to the nearest emergency room.

Consent Substance *

I acknowledge that I have had the opportunity to ask questions regarding treatment, risks, benefits, office policies, and consent for care, and all questions have been answered to my satisfaction.I understand that alcohol, marijuana/cannabis, illicit substances, supplements, and non-prescribed medications may interfere with treatment, worsen symptoms, or increase medication risks. I agree to provide accurate information regarding my medical history, medications, symptoms, and substance use.

Consent Cancellation *

I understand that missed appointments or cancellations without appropriate notice may result in a $50 no-show/late cancellation fee.

Consent Acknowledgment *

I acknowledge that I have had the opportunity to ask questions regarding treatment, risks, benefits, office policies, and consent for care, and all questions have been answered to my satisfaction.

Patient Signature:

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Date