Set Point Health | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Current Diagnosis

Current Medications

Who currently prescribes your psychiatric medication?

Urgency

Routine (2-4 weeks) or Urgent (1-2 weeks)

Are there any safety concerns?

If you or someone else is in immediate crisis, please contact emergency services (9111) or a crisis line (988).

Previous Mental Health Treatment

therapy , psychiatric care, hospitalizations, previous medication trials...

Additional Information That May Help Guide Care

School struggles, family stressors, diagnostic questions...

Legal Decision-Making / Custody

Does the patient have any custody or legal decision-making arrangements that may affect consent for treatment?

No known custody or legal concerns Parents share legal custody / decision-making One parent has sole legal custody Patient has a legal guardian Court involvement or custody dispute Unsure Patient is an adult

Will all legal guardians consent to treatment?

Yes No Unsure Patient is an adult

If legal custody or guardianship arrangements exist, documentation may be required before treatment can begin. If there are custody or legal considerations, please briefly describe (do not include names or identifying information)

"Parents divorced, mother has medical decision-making"

Who will be attending the first appointment?

Parent / Legal Guardian Both Parents One Parent Other Caregiver (they will need to be added to the release of information) Patient is an adult

Patient Age Group

Under 12 12-14 15-17 18+

Reason for care

What is the reason for seeking care?

Anxiety Depression / Mood Behavioral Issues ADHD Evaluation or Management Grief Relationship Issues Emotional Regulation Trauma Second Opinion Diagnostic Clarification Documentation (IEP/504/Advocate for services) Other

What kind of care is being sought?

Psychotherapy Medication Management Psychotherapy + Med Management Other Not Sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons recently (6 months) Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Is the patient currently experiencing any of the following?

Passive thoughts of death or self-harm Recent suicidal thoughts Recent suicide attempt Aggressive or unsafe behavior Psychiatric hospitalization in the past 30 days None of the above

Administrative

Inquiry reason

Referral source

Enter how you were referred to our services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Set Point Health is a self-pay practice

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Preferred modality

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.