We are required to check the PA Prescription Drug Monitoring Program (PDMP) database for the controlled substance for each patient. If there is an error in name or date of birth, we won’t be able to check accurately. Please enable JavaScript in your browser to complete this form.Patient's Legal Name *FirstLastDate of Birth *EmailPhone Number *Are you currently working or in school? If yes, where? are you a self pay patient or do you have insurance. if yes, what mental health coverage do you have?Do you have any health concerns? What are you hoping to gain from our facility? Please explain. Have you ever been to any other psychiatrist/therapist previously? If yes, why are you seeking to change?Have you ever been prescribed mental health medication? If yes, please provide name, dosage, and frequency.Have you ever been placed in an inpatient facility in the last year? Agreement all information the user post is correct *I hereby certify that the above statements are true and correct to the best of my knowledge.EmailSubmit
