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Section 1 — Services requested
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Service Requested
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Brief reason for seeking psychiatric care at this timeShort Text Field
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Section 2 — Safety screening
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Have you been hospitalized for psychiatric reasons in the past 6 months?
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Are you currently experiencing thoughts of harming yourself or others?
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Section 3 — Insurance and referral
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Insurance Selection
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Enter other insurance
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Agreement to self-pay fee structure, if applicable
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Referral source / How did you hear about Dr. Walker
• • •
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Section 4 — Pharmacy
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Pharmacy Name
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Pharmacy Phone
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Pharmacy Address
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Section 5 — Primary care physician
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PCP Name
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Practice / Clinic
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Practice Phone
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Practice Fax
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Section 7 — Additional information
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Additional notes for practice staff
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