New Patient Form

This form is to be completed by the patient, parent/legal guardian, or a person the patient has authorized to complete this form. Please do not complete this form if you do not have the patient's consent.

This form is not designed to respond to psychiatric emergencies. If you are currently experiencing a psychiatric emergency, please contact your current mental health provider or go to your nearest emergency room.


PLEASE NOTE:

Due to our current patient volume, the Anxiety Disorders Center has a wait list of approximately 3 months for individual weekly therapy. Wait times will be shorter for those interested in our accelerated treatment programs, research projects (including therapist-assisted self-directed treatment), and group therapy for Hoarding Disorder (group starts in May).

We apologize for the inconvenience and thank you for your patience.


* = required field

Information on individual in need of treatment:

Insurance Information

The Anxiety Disorders Center does not accept state funded insurance such as HUSKY, Medicaid, and Title 19.

Who should we contact regarding this form?

Current Symptoms / Treatment

Are the following present?

Have you ever been diagnosed with or had problems with the following:

Past Treatment History

Other Information

(If you require regular weekly appointments after 3PM, there may be an additional wait time to schedule your initial evaluation.)

If after clicking 'Send' nothing appears to be happening, click here to see if any fields were entered incorrectly.

Anxiety Disorders Center / Center for Cognitive Behavioral Therapy