Welcome to Premier BHS.

Please complete the following Consultation Form and our patient coordinator will review your information and call you to set up an appointment.

Name

First Name

Last Name

Phone

(###)

###

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How can we help you?

ARE YOU CURRENTLY ON PSYCHIATRIC MEDICATIONS? If yes, what are they?

ARE YOU STABLE ON YOUR MEDICATIONS?

ARE YOU CURRENTLY SEEING A PSYCHIATRIST? IF YES, WITH WHOM AND WHEN LAST SEEN

ANY INPATIENT/OUTPATIENT TREATMENT FOR MENTAL HEALTH OR SUBSTANCE ABUSE? IF YES, WHERE AND WHEN?

ANY HISTORY OF SUICIDE ATTEMPT? IF SO PLEASE PROVIDE US WITH DETAILS ABOUT THE INCIDENT.

DO YOU EXPERIENCE ANY SYMPTOMS OF DEPRESSION, ANXIETY AND PANIC ATTACKS? HOW OFTEN?