• Psychiatric New Patient Initial Request Form

    If this is a medical emergency or you feel you are in danger, please call 911 or go to your nearest emergency room immediately.
  • Our Locations:*
  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex assigned at birth:*
  • Gender:*
  • Preferred Pronouns:*
  • Format: (000) 000-0000.
  • What service are you looking to schedule?*
  • For Treatment-Resistant Depression (TRD)
  • Release of Information (ROI)- Please list below individuals (family, spouse, friend) with whom your provider can discuss your care or release your psychiatric medical records. If you do not want anyone to discuss your medical records, check "Do Not Release Medical Records" in the last column.
    Rows
  • Do you have any family members established with Psych Atlanta*
  • Have you ever been seen by Psych Atlanta?*
  • Have you ever been seen by Georgia Psychiatry and Sleep?*
  • Format: (000) 000-0000.
  • Do we have your consent to contact your primary care provider to discuss your care?*
  • Format: (000) 000-0000.

  • Educational/Legal/Social History

  • Are you currently in school?*
  • Are you currently employed?*
  • Active Combat*

  • Substance Use History

  • Do you currently use any of the following?*

  • Past Medical History

  • Abuse/Domestic Violence*
  • ADHD*
  • Anxiety/Panic Disorder*
  • Auditory Hallucinations*
  • Autism Spectrum Disorder (ASD)*
  • Bipolar Disorder*
  • Developmental or Behavioral Disorders*
  • Eating Disorder*
  • Learning Disorder*
  • Major Depressive Disorder*
  • Postpartum Depression/ Anxiety/ Psychosis*
  • PTSD*
  • Schizophrenia*
  • Visual Hallucinations*
  • AIDS/HIV*
  • Amnesia*
  • Aneurysm*
  • Autoimmune Conditions*
  • Arthritis/Joint issues:*
  • Blood Disorders:*
  • Brain/Head injury:*
  • Brain Tumors:*
  • Cancer:*
  • Cardiac Problems:*
  • COPD/pulmonary problems:*
  • CVA/Stroke/TIA:*
  • Diabetes:*
  • Epilepsy/Seizure disorder:*
  • Fibromyalgia:*
  • GYN issues:*
  • GI Problems:*
  • Hearing Problems:*
  • High cholesterol/Hyperlipidemia:*
  • High blood pressure/Hypertension:*
  • Head Trauma/Injury*
  • Hyperlipidemia*
  • Kidney Disease:*
  • Liver Disease:*
  • Metal Implants:*
  • Neurological Problems:*
  • Obesity:*
  • Prone to UTI's:*
  • Skin Problems:*
  • Thyroid Problems:*
  • Vision Problems:*

  • Outpatient Psychiatric History

  • Format: (000) 000-0000.
  • May we speak to your current therapist?
  • Have you ever seen a psychiatrist?*
  • Are you currently seeing a provider for medication management?*
  • Can we speak to your current provider?*
  • Have you ever been diagnosed with a personality disorder?*
  • Have you ever been diagnosed with an eating disorder*
  • Failed Medications*
  • History of:*

  • History of Psychiatric Hospitalizations

  • Past Psychiatric Hospitalization?*
  • Prior suicide attempts:*
  • Prior self-injurious behavior:*
  • Past aggression:*
  • History of Mania/Hypomania*

  • Family History

  • Do you have any family members with psychiatric illness or substance abuse problems?*
  • Method of Payment:*
  • Insurance Plan:
  • Interested in Our Research Studies?*

  • By signing/submitting your New Patient Request Form:

     I am aware Hightop Health DOES NOT provide services for patients that are seeking a one time court ordered appointment, Workers Compensation cases, appointments for FMLA/Disability Forms ONLY, or patients seeking service animal forms ONLY.

     I am aware Hightop Health providers DO NOT fill out any forms until I have been an established patient for at LEAST 6 months.

    Based upon clinical assessment and judgement, your provider will determine the appropriate treatment options and in partnership with you will individualize prescriptions tailored to your needs and goals. There should not be an expectation to continue any prescriptions you are currently taking or start new medications.

  • Today's Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: