Patient Application Form - The Eupatheia Center - Positive Psychological Practice

Patients Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Guardians Name

(if patient is child)

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Secondary Phone

(###)

###

####

Purpose of appointment:

psychological evaluation

Therapy

Both

What type of appointment would you like?

Virtual appointment

Brunswick office

Main reason for appointment:

Emotional Issues

Behavioral Issues

ADHD Evaluation

Autism Evaluation

Anxiety / Depression

PTSD

Marriage Counseling

Court Situation

Are you currently involved in legal or custody proceedings?

Yes

No

Are you currently seeking disability?

Yes

No

Payment for Services

Insurance

Self-pay