Assessment Form – Mid-South Psychiatric Services

* Indicates required fields

Patient name (Children , Adolescents and Adults accepted)

DOB (Date of Birth)

I agree to receive Tele-health services

Parent or Guardian Name ( if applicable)

Patient Address

Street Address

City

State

Zip Code

Email

Cell Phone

Select an accepted Insurance or self-payment

Insurance ID No.

Group No.

Referral source, (self, PCP, family, specialist)

Current or Past mental health provider

Name

Date of last visit

Current or Past Primary care provider

Name

Date of last visit

Current Diagnosis or Problem/Concern

Substance Abuse treatment services are not offered and Controlled Substances except for ADHD are not prescribed

Hospitalized for psychiatric illness

Yes

No

Date if Yes

Hospital Name

Disclaimer

I consent to tele-health services and understand I will be contacted once an opening becomes available. Completion of this form is not a guarantee of services. Referrals from hospitals and primary care clinics are prioritized. If you need immediate psychiatric care, do not submit this form and seek emergency care or call 911.