Todays Date *

MM

DD

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Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

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Work Phone

(###)

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SMS Opt In *

By selecting “Yes” you are opting into or consenting to receive SMS messages from staff at Stepping Stones Psychiatry. You may opt out at any time by sending a text to 413.277.7717 stating “STOP”.

Yes, I want to receive messages via text

No, I do not want to receive messages via text

Are you currently seeing a therapist?

Yes

No

Therapist Phone

(###)

###

####

Are you currently seeing a psychiatrist?

Yes

No

Phone of Psychiatrist

Records will need to be forwarded.

(###)

###

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History of Suicidal Thoughts?

Yes

No

History of Suicidal Atttempts?

Yes

No

History of Alcohol Abuse?

Yes

No

History of Substance Abuse?

Yes

No

Have you ever been hospitalized in a psychiatric unit before?

Yes

No

If yes, when was the last inpatient experience?

MM

DD

YYYY