CONTACT US - Supplemental Mental Health Questionnaire

New Patients

Supplemental Mental Health Questionnaire

For patients seeking mental health services who have already filled out a contact form for primary care, please complete the form below.

Please complete the form below prior to calling our office directly.

Thank you!

Name *

First

Last

Preferred Pronouns

Date of Birth *

I am under the care of a mental health provider but I am looking to make a change:

I have been hospitalized in the last year for my mental health.

I have been previously diagnosed with the following mental health conditions:

I am taking the following mental health medications:

Please check behaviors or symptoms that occur more often than you would like them to:

Are you able to go up stairs? (In Salem, most of our offices are located upstairs, but accommodations can be made for downstairs visits.)

Any additional information that would assist us in understanding your problems or concerns (both mental health and physical health conditions):

Email *

Message