• Complete this form to make a new patient appointment.

    Call us at (770)438-1799 ext 2 with any questions
  • Pick your desired primary location
  • Are you filling out this paperwork on behalf of someone under 18?*
  • Sex assigned at birth*
  • Format: (000) 000-0000.
  • Gender*
  • Preferred Pronouns*
  • 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.*
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  • Pictures of the front and back of your insurance card and driver's license are required PRIOR to scheduling an appointment.
  • Subscribers Date of Birth
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    2 digit month, 2 digit day, 4 digit year
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  • What service are you looking to schedule?*
  • What symptoms are you currently experiencing?*
  • Have you ever seen a psychiatrist or counselor in the past?*
  • How did you find out about Hightop Health?*
  • Have you been a patient in a psychiatric hospital or in a rehab program within the past year for a drug/alcohol or behavioral problem?*
  • Office Policies*
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  • Scales/Questionnaires

  • PHQ 9 - Over the last 2 weeks, how often have you been bothered by any of the following problems?*
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  • If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*
  • GAD 7 - Over the last 2 weeks, how often have you been bothered by the following problems?*
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  • ASRS*
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  • ESS - How likely are you to doze off/fall asleep in the following situations, in contrast to just feeling tired?*
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  • MDQ*
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  • If you answered yes to more than one above, have several of these ever happened during the same period of time?*
  • How much of a problem did any of these cause you? Like being unable to work, having family/money/legal troubles, getting into arguments/fights?*
  • Have any of your blood relatives had manic-depressive illness or bipolar disorder?*
  • Has a healthcare professional ever told you that you have manic-depressive illness or bipolar disorder?*
  • RMS *
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  • How often do you have drinks containing alcohol?*
  • How many standard drinks containing alcohol do you have on a typical day?*
  • How often do you have six or more drinks on one occasion?*
  • Sleep Routine Questionnaire*
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  • Any major medical (non-psychiatric) hospital admissions?*
  • Do you ever hear voices or experience hallucinations? Or have you in the past?*
  • Do you have a history of addiction?*
  • What is/was your substance of choice:*
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  • Have you ever experienced drug withdrawals/substance use-related seizures?*
  • Do you attend AA/NA/12-Step meetings?*
  • Review of Systems*
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  • Family History*
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  • Are you currently pregnant?*
  • Are you currently breastfeeding or pumping breast milk for infant feedings?*
  • Do you smoke cigarettes?*
  • What time do you wake up and go to sleep on a typical work/school day?*
    Until

  • Social History

  • If on disability, is it for*
  • Legal History*
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  • Have you served in the US military?*

  • Are you interested in our clinical research trials?*
  • Today's Date *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex*
  • Format: (000) 000-0000.
  • Gender*
  • Preferred Pronouns*
  • Family Information*
    Rows
  • Rows
  • 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 to release your information to anyone, type "N/A" in the Name box and "Do not release medical information" in the Relationship Dropbox.*
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  • Office Policies*
    Rows
  • What service are you looking to schedule?*
  • What symptoms are you currently experiencing?*
  • Have you ever seen a psychiatrist or counselor in the past?*
  • How did you find out about Georgia Psychiatry and Sleep?*
  • Have you been a patient in a psychiatric hospital or in a rehab program within the past year for a drug/alcohol or behavioral problem?*

  • PLEASE GET YOUR CHILD'S/TEEN'S INPUT IN ANSWERING THE FOLLOWING SCALES (If developmentally appropriate).
  • PHQ 9 - Over the last 2 weeks, how often has your child/teen been bothered by any of the following?*
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  • If you checked off any problems, how difficult have these problems made it for your child/teen to do school work/activities, or get along with other people?*
  • In the past year, has your child/teen felt depressed or sad most days, even if they felt okay sometimes?*
  • Has there been a time in the past month when your child/teen had serious thoughts about ending their life?*
  • Has your child/teen ever, in their whole life, tried to kill themself or made a suicide attempt?*
  • GAD 7 - Over the last 2 weeks, how often has your child/teen been bothered by the following problems?*
    Rows
  • ADHD*
    Rows
  • ESS - How likely is your child/teen to doze off or fall asleep in the following situations, in contrast to just feeling tired?*
    Rows
  • MDQ - Has there ever been a period of time when your child was not their usual self and...*
    Rows
  • Sleep Routine Questionnaire*
    Rows
  • What is your child/teen's typical sleep schedule on a school/work day?*
    Until
  • Is your child generally healthy?*
  • Review of Systems- Please indicate if your child/teen has a history of the following: *
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  • Has your child/teen been more irritable than usual?*
  • Has your child/teen been isolating from friends/family?*
  • Have your child/teen's grades dropped from their baseline?*
  • Does your child/teen have behaviors that are of concerns?*
  • Does your child/teen have access to any weapons in their home(s)?*
  • Does child/teen live with both biological parents?*
  • Has either parent/guardian served in the US military?*
  • Have there been any major changes in the life of your child/teen in the last few years?*
  • Does your child/teen have a history of abuse, neglect, or bullying?*
  • Has your child/teen ever been arrested or had charges filed against them?*
  • Has your child/teen ever been cruel to other people or animals?*
  • Were there any problems in the pregnancy/birth of this child/teen?*
  • Did your child/teen meet all developmental milestones in a timely manner? (walking, talking, potty training, etc.)*
  • Has your child/teen received any special classes or assistance in school? (Special education classes, tutoring, gifted classes, etc.)*
  • Does your child have any issues making or keeping friends?*
  • Has your child/teen abused any of the following substances?*
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  • Does your child/teen smoke or vape?*
  • Does anyone in the household smoke cigarettes?*
  • Does anyone in the family/household have a history of addiction?*
  • If yes, has this family member ever experienced drug withdrawals?*
  • If applicable, is your teen currently pregnant?*
  • If applicable, is your teen breastfeeding or pumping breast milk for infant feedings?*
  • Has your child/teen ever severely restricted food intake or made themselves intentionally throw up or engaged in other behaviors to control their weight?*
  • Family Medical History*
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  • Is your child/teen allergic to any medications?*
  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: