New Patient Screening Questionnaire

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New Patient Screening Questionnaire

If you would like to establish a client-provider relationship with Polaris Mental Health Services, please complete and submit the screening questionnaire. This is required to be submitted before we can give you an appointment.

I understand that information gathered from this questionnaire and any medical records is to determine if my needs can be met by this practice. Therefore, submitting this form does not automatically establish a provider-patient relationship. *

Yes

I consent to the provider viewing my medical records (if submitted), including information contained in the Prescription Monitoring Program and any electronic records. *

Yes

First Name

Last Name

Phone

Birthday * required

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Why are you seeking care?

Select all that apply: * Required

I am completing this form for myself

I am completing this form on behalf of someone else (the person's name and information is provided above

I am (person needing service is) currently pregnant or breastfeeding

I have (person needing service has) been admitted to the hospital for a psychiatric reason recently

I have (person needing service has) current/pending legal issues

I have (person needing service has) a history of violence or aggressive behavior

The prospective client is "biologically" male

The prospective client is "biologically" female

The prospective client has insurance

The prospective client does not have insurance and plans to pay of out pocket

Thanks for contacting us; we will get back to you as soon as possible!

Polaris Mental Health Services, PLLC is NOT a crisis service.
If you are experiencing a medical emergency, call 911; if you are experiencing a mental health crisis, call 988, or go to your nearest emergency room.
Click here for other crisis resources. Please, do NOT leave sensitive Protected Health Information (PHI) on the company voicemail.

info@polarismhs.com | P: (571) 267-8844 | F: (949) 404-8012 | 10432 Balls Ford Road, Ste 300 - #609, Manassas, VA 20109

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