1. How old are you? *

0 - 17 years old

18 years old + above

2. Will you need any language interpretation services? *

Yes

No

3. Is there any worker's compensation, or legal issues related to treatment? *

Yes

No

Please describe worker's compensation or legal issues.

4. Have you had auditory, visual hallucinations or paranoid thoughts in the past 6 months? *

Yes

No

Please describe recent auditory or visual hallucinations or paranoid thoughts.

5. Are you currently struggling with addiction or seeking substance abuse treatment to a substance other than marijuana or nicotine? *

Yes

No

Please explain your addiction or substance use treatment you are seeking.

6. Are you looking to be prescribed one of the following medications: methadone, suboxone, Subutex, buprenorphine/naloxone or belbuca? *

Yes

No

Please list medications you are currently prescribed. *

7. Have you had a suicide attempt in the past 3 months? *

Yes

No

Service Requested *

Psychiatric Evaluation

Medication Management

TMS

Spravato

Primary Reason For Visit *

How did you hear about us? *

Name of referral

Sex Assigned at Birth *

Male

Female

Street Address *

City *

State *

Country

ZIP code *

How will you be paying for your visits? *

Primary Insurance

Name of Other Insurance

Do you have a Secondary Insurance?

Yes

No

Secondary Insurance

Upload a photo of the front & back of your Insurance Card(s)

Upload a photo of the front of your Driver’s License or Other ID card

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I consent to receive marketing text messages from Evolve Brain Health at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

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