Patient's Name * First Name Last Name Phone * Best number to reach you (###) ### #### Email Relation to patient * Please select (1) of the following options Self Guardian Guardians: Please enter your name below First Name Last Name Patient's Date of Birth * MM DD YYYY Location of patient * Is the patient currently receiving mental health treatment? * Yes No Currently seeing a therapist? * Yes No Currently taking psychiatric medications? * Yes No If so, please list in field below Which services are you interested in at Transcendental Wellness? * Please select all that apply Individual Therapy Medication Management Please select your preference for treatment: * In Person Telehealth No Preference Best days/times to reach you * Insurance (If applicable) How did you hear about this practice? * e.g. Search engine (Psychology Today, Headway, Alma), or a referral from friend/therapist/provider *please include the name of the individual who referred you, or search engine used* Thank you!Our office will be in touch with you shortly Consultation Form New Patient
