6804 Greenwood Ave North

Weekdays: 8:00 am - 5:00 pm

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206-457-1861

8 am - 445 pm

206-257-7780

9 am - 12 pm

1 pm - 445 pm

FAX 206-558-1784

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New Mental Health Patient Registration Form

August 22, 2022 / Amna Mirza

PLEASE READ - After we receive this completed registration form, we will email you the relevant paperwork (multiple forms) necessary for the appointment. Please allow us 24 hours to send the email. Keep an eye on your spam folder! Once we have received your completed and signed paperwork, we will reach out to you to find a time and day for the appointment.

Name *

First

Last

Date of Birth (MM/DD/YYYY) *

Phone Number *

Email *

Do we have your consent to send you text, voice and/or email messages regarding your appointments? *

Entire Home Address (Street address, Apt #, City, State, Zip Code) *

Medical Insurance Name *

Insurance ID (with Prefix) *

Insurance Group # (if none type in NA) *

Primary Subscriber's First & Last name - Medical Insurance *

Primary Subscriber's Date of Birth (MM/DD/YYYY) *

Reason for Appointment Request *

Please describe the main reason(s) you are seeking mental health support at this time:

Current Symptoms (Check all that apply)

Depression
Anxiety
Panic attacks
Mood swings
Trouble sleeping
Irritability or anger
Difficulty concentrating
Low energy or fatigue
Appetite changes
Suicidal thoughts
Self-harm
Hallucinations or delusions
Substance use concerns

Duration of Symptoms *

How long have you been experiencing these symptoms?

Previous Mental Health Care - Have you seen a therapist, psychiatrist, or other mental health provider before? *

If yes, please provide details (provider name, dates, diagnoses, treatment, etc.):

Current or Past Diagnoses (if known) *

Any mental health diagnoses you’ve received in the past

Current Medications -Are you currently taking any psychiatric medications? *

If yes, please list medications and dosages:

Safety Concerns -Are you currently experiencing thoughts of harming yourself or others? *

If yes, please explain:

Substance Use- Do you currently use alcohol or other substances? *

If yes, what and how often?

Additional Information - Is there anything else you would like us to know?

Phinney Primary Care & Wellness

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6804 Greenwood Ave N, Seattle, WA 98103

206-257-7780