New Patient Questionnaire

If you are having thoughts of suicide call 911 or proceed directly to closest hospital.

Please complete all of the fields to the best of your ability and your answers will be submitted to Dr. Carmosky for her to review. Enter None for any fields that do not apply.
Note: This form must be completed by the patient and not by a 3rd party.
Please check if you need a referral from your Primary Care Physician prior to making an appointment.
We do not accept Medicaid or Medicare.
Enter None if you are not taking any medications or supplements.
Enter None if you do not drink alcohol.
Enter None if you have not used recreational drugs in the past 6 months.
Enter None if you have not had any previous treatment.
Enter None if you do not have anything else we need to know to assess your needs.
Please type the number in blue