• 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.
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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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  • 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?*
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  • Scales/Questionnaires

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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?*
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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?*
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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?*
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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?*
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  • Have you ever experienced drug withdrawals/substance use-related seizures?*
  • Do you attend AA/NA/12-Step meetings?*
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  • Are you currently pregnant?*
  • Are you currently breastfeeding or pumping breast milk for infant feedings?*
  • Do you smoke cigarettes?*
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  • Social History

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

  • Are you interested in our clinical research trials?*
  • Today's Date *
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  • Sex*
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  • Gender*
  • Preferred Pronouns*
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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 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).
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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?*
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  • Is your child generally healthy?*
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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?*
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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?*
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  • Is your child/teen allergic to any medications?*
  • Today's Date*
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