Southeast Virginia Psychiatry

Reason for care

What is the reason for seeking care?

Limited to 600 characters

What kind of care is being sought?

Medication Management Psychotherapy Spravato Consultation Ketamine Consultation TMS Consultation Other Unsure

Have you had mental health treatment in the past? If so, what and when?

(e.g., psychotherapy, medication management, TMS, inpatient hospitalization)

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Do you have any previous/current mental health diagnoses?

(e.g., ADHD, PTSD, Bipolar Disorder, OCD, Major Depressive Disorder, Generalized Anxiety Disorder)

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Please list any psychotropic medications you are currently taking and the dosages:

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Are you currently experiencing suicidal thoughts? If not currently, have you ever?

Yes No

Are you currently working? If so, what is your occupation?

Do you currently drink alcohol and/or use recreational drugs? If yes, describe the amount, type, and how often.

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Do you have any non-mental health related medical conditions? (e.g. hypertension, diabetes, asthma, etc.)

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Administrative

Referral source

How did you find us?

Referred by:

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

Please list any and all insurance plans, including primary and secondary plans (if applicable). If you don't plan to use insurance, please put "N/A"

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Insurance card upload

Upload a photo of your insurance card

Client Preferences

Is there anything that you'd like us to know?

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.

Who would be receiving care?

Your info