New Patient Questionnaire | HPA Psychiatry

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Mon to Thu 9am to 5pm · Fri 9am to 4pm · 150 Pine Forest Dr, Ste 804, Shenandoah, TX Open Monday to Friday Call or text (936) 270-8011

HPA PsychiatryHeartland Physicians Associates

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New patients · Form 1 of 2

New Patient Questionnaire

About 5 minutes. Nothing you type is sent anywhere. When you're done, print it or save it as a PDF and bring it to your visit.

HPA Psychiatry · Heartland Physicians Associates
150 Pine Forest Dr, Suite 804, Shenandoah, TX 77384 · (936) 270-8011 · Fax (936) 270-8012

New Patient Questionnaire

We restored the answers you had typed earlier in this session.

Your visit

Who would you like to see?

Dr. Shaikh Jennifer Cameron, NP Sharina Robinson, NP Alexy Joseph, NP Shayna Dutcher, NP No preference

Type of visit

New patient Follow-up

Prefer to be seen

In office Telemedicine

Referred by Today's date

Why do you want to see us?

About you

Full name Age

Phone Email

Address

Insurance Diagnosis, if you've been given one

Current medications

Psychiatric history

Previous psychiatrist's name Reason for leaving

History of psychiatric hospitalizations

Do you currently see a therapist or counselor?

Yes No

If yes, who?

Safety

If you're having thoughts of hurting yourself right now, please stop and call or text 988, or go to the nearest emergency room. This form isn't monitored.

Current suicidal thoughts?

YesNo

If yes, do you have a plan?

Past suicide attempts?

YesNo

If yes, when?

Currently self-harming?

YesNo

If yes, last time?

Homicidal thoughts?

YesNo

If yes, regarding whom?

Hearing things others don't?

YesNo

If yes, like what?

Seeing things others don't?

YesNo

If yes, like what?

Substance use

History of alcohol abuse?

YesNo

History of substance abuse?

YesNo

History of prescription abuse?

YesNo

Details, if any

Medical, social, and family history Past medical history Social history

Pregnant?

YesNoNot applicable

Breastfeeding?

YesNoNot applicable

Family history of psychiatric illness

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HPA PsychiatryHeartland Physicians Associates

Psychiatric care for children, adolescents, and adults in Shenandoah and The Woodlands, Texas.

In a crisis, call or text 988, or go to your nearest emergency room.

Practice

What we treat Our team New patient forms Patient resources Request an appointment

Conditions

Anxiety Depression ADHD Bipolar disorder PTSD Personality disorders

Contact

Call or text (936) 270-8011 Fax (936) 270-8012 [email protected] 150 Pine Forest Dr, Suite 804
Shenandoah, TX 77384 Mon to Thu 9 to 5 · Fri 9 to 4

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