Become a New Patient

Mid Island Mental Health

New Patient Inquiry & Pre-Screening Questionnaire

Important Notice:

Completion of this form is a request for services only and does not establish a physician-patient relationship. Submission of this form does not guarantee acceptance into treatment. A member of our clinical or administrative team will review your information and contact you regarding next steps.

If you are experiencing a psychiatric emergency, active suicidal thoughts, or are in crisis, please call 988, dial 911, or go to your nearest emergency room immediately. This form is not monitored in real time.

Full Legal Name *

Date of Birth *

Address *

Email Address *

Phone Number *

By providing your mobile number, you consent to receive SMS messages from Jim Morgan NP in Psychiatry for Mid Island Mental Health related to appointments and care coordination. Message frequency varies. Message and data rates may apply. Reply STOP to opt out. View our Privacy Policy.

How do you intend to pay for services? *

If utilizing insurance coverage, please complete the following:

Name of Insurance Carrier

Policyholder’s Full Legal Name (if other than the patient)

Policyholder’s Date of Birth

Member Identification Number

Group Number

If you carry secondary insurance, you must also provide complete information for that policy, including carrier name, policyholder details, member ID number, and group number.

Please Note: Verification of benefits is not a guarantee of coverage or payment.

Patients are ultimately responsible for any deductibles, co-payments, co-insurance, or non-covered services.

Please describe the primary reason you are seeking treatment at Mid Island Mental Health:

Have you ever been diagnosed with a mental health condition?

Have you ever been psychiatrically hospitalized?

Please provide date for admission

Please provide reason for admission

Do you have a history of aggression, violent behavior, or significant anger control issues?

Do you currently have any pending legal matters (e.g., court cases, probation, disability claims related to psychiatric care)?

Please explain

Do you have a history of substance use or substance use disorder?

Please specify substances used

Duration

Whether use is current or in remission

Do you currently have a therapist?

Therapist Name

Therapist Practice

Therapist Phone Number

Do you have any significant medical conditions (e.g., neurological disorders, cardiac conditions, chronic illnesses)?

Please List

Additional Information

Please provide any additional information you believe may be relevant to your care:

Acknowledgment and Consent

By submitting this form, I acknowledge and agree to the following:

I understand that completion of this form does not establish a physician-patient relationship.

I understand that Mid Island Mental Health may determine, in its clinical discretion, whether I am an appropriate candidate for services.

I certify that the information provided is accurate and complete to the best of my knowledge.

I understand that electronic communication carries inherent privacy risks, and I consent to being contacted using the information provided.

I understand this form is not intended for emergency communication.

Electronic Signature:

Electronic Signature (jpg,png,pdf only)

Choose File

Typed Full Name *

Date: