Get in Touch With Us Now

Intake Request

Please fill out the details below with accurate information to ensure effective assistance.

Thank you for trusting TruMediq with your client’s mental health needs. Please fill out the form and a Managed Care Specialist will be in contact with you shortly!

Intake Request

Patient Information

Full Name:

First

Last

Date of Birth:

Gender:

Emergency Contact Name:

Relationship:

Phone:

Presenting Concerns

What brings you to seek psychiatric care?

Duration of current concerns:

Previous psychiatric diagnoses (if any):

Current medications (include dosage and frequency):

Medical and Psychiatric History

Have you ever been hospitalized for psychiatric reasons?

Please provide details (date, location, reason):

Do you have a history of trauma?

Please explain (optional):

Do you have a history of substance use?

Please provide details:

Family History

Does anyone in your family have a history of mental health conditions?

Please provide details:

Social History

Current Occupation:

Marital Status:

Living Situation:

Support System (friends, family, community resources):

Referral Information

How did you hear about us?

Referring Provider (if applicable):

Phone Number:

Additional Notes

Consent and Acknowledgment

I confirm that the information provided is accurate to the best of my knowledge.

I consent to outpatient psychiatric care and understand the nature of the treatment.

Signature:

Clear

Date

If you are human, leave this field blank.

Intake Request

Patient Information

Presenting Concerns

Medical and Psychiatric History

Family History

Social History

Referral Information

Additional Notes

Consent and Acknowledgment

Treatments

Quick Links

Legal

Address