Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Gender Identity
*
Male
Female
Transgender
Non-binary
Rather not say
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency contact
*
(###)
###
####
Email
*
Message
*
Previous diagnoses
Past and current medications
(including any supplements)
Allergies
(medication, food, environmental)
Hospitalizations or surgeries
(if so, explain)
Family medical history, especially of mental health conditions
Dietary habits
Exercise routines
Alcohol, tobacco, and drug use
Sleep patterns
Previous psychiatric treatment or counseling
Current mental health providers (if any)
History of psychotherapy or other mental health services
Known triggers or stressors
Description of current mental health symptoms
Concerns leading to the consultation
Impact of these concerns on daily life
(work, relationships, etc.)
Patient’s goals or expectations from therapy
Specific areas or issues they wish to address
Consent to treatment
*
Acknowledgment of privacy practices
*
Insurance and Payment. I am an out-of-network provider and do not participate with insurance plans. Payment is due at the time of service. Please contact me to discuss the fee schedule.
Cancellation Policy. If you are unable to attend your scheduled appointment, please notify Dr. Park at least one week in advance, or you will be subject to payment for the full session fee.
Confidentiality. The law protects the relationship between a client and a psychiatrist. Information cannot be disclosed without written consent.
Exceptions include:
***Suspect of child abuse or dependent adult or elder abuse, where immediate reporting to
state agencies is required.
***In case of risk of serious bodily harm to other person(s), care providers are required by
law to report to authorities and inform the intended victim.
***In case of acute risk of harm to patient by themselves, every effort will be made to enlist
the client’s cooperation to protect them from harm. If unable to cooperate, action will be
taken without their permission in order to ensure their safety.