New Patient Inquiry Form | Sarah K Covert NP

Welcome!

We'd like to learn more about what's bringing you to us. The following steps will help us better understand your experiences, goals, and preferences for care.

New Patient Inquiry

Once this intake is completed, it will be reviewed by the providers and someone will contact you. This intake does not guarantee an appointment with this practice.

First Name

Date of Birth

Last Name

Phone Number

Street Address

State

City

Zip Code

Reason for visit (symptoms, diagnosis):

List all psychiatric medications you are currently taking including the dose:

If currently on psychiatric medications, who is your current prescriber?:

When did you last use?

If Yes, what is your drug of choice?:

How much is your current use? (Please put N/A if not applicable)

(If feeling suicidal please call 911 or go to the nearest emergency room)

Who referred you?

If Yes, please provide details including last time you had suicidal thoughts:

If Yes, please provide details including date when this happened:

If Yes, please provide details including last date when this happened:

If Yes, please provide date & location:

If Yes, please explain:

Who is your insurance carrier?

Please note, our providers do not participate with all listed insurances

Insurance Subscriber/Member ID# (Include any letters):

If your insurance is through someone else, please provide name and date of birth:

Name

Date of Birth

I am a holistic practitioner meaning I don't rely on only medication to treat mental health issues.

Thanks for submitting!