Pre-Intake Questionnaire

To better serve you and to ensure Christine Doucette-PMHNP-BC is rendering services within her scope of practice, we request that all potential patients please complete the following brief questionnaire. Please note that completing this mandatory questionnaire is the first step of the scheduling process, but if it does not appear that Christine Doucette, PMHNP-BC can meet your treatment needs, we will notify you directly. Completing this questionnaire does not result in active patient status in our practice, and no therapuetic relationship exists until you become an active patient and have your intake appointment scheduled. Thank you in advance, and we look forward to connecting with you soon!

For whom are you seeking services?

Myself

My Child

Other

If you selected "Other," please specify:

Relationship to patient:

Patient's Legal Name:

Patient Date of Birth:

Month

Day

Year

Contact Number:

Email Address:

Street Address:

City:

State:

Zip:

Referred By:

Have you been in therapy before?

Yes

If so, was it helpful?

Yes

Are you currently under the care of a therapist?

Yes

If so, whom?

Reason for seeking services:

Have you previously been diagnosed with any mental health conditions by a licensed mental health provider?

Yes

If so, please indicate your diagnosis/diagnoses:

Do you have a history of psychiatric hospitalizations?

Yes

If yes, please provide dates and reasons for hospitalization(s):

Are you currently experiencing legal trouble or seeking testimony or medical records for court involvement

Yes

Are you currently seeking services regarding a Worker's Compensation claim?

Yes

Please note that Christine Doucette, PMHNP-BC currently offers services only via telehealth. Are you open to telehealth appointments?

Yes

What is your behavioral health insurance carrier?

What is your member ID?

What is your group ID?

What is the patient's relationship to the subscriber?

Important Practice Information:

Please note that Christine Doucette, PMHNP-BC does not offer weekend/evening/holiday services. Patients experiencing life-threatening emergencies outside of normal business hours must dial 911 or report to their nearest emergency room. Patients with urgent treatment needs should not expect a response outside of normal business hours.
In the event that Christine Doucette, PMHNP-BC is not in-network with your insurance provider, our practice can provide you with a superbill so that you can file out-of-network claims on your own behalf if your plan has out-of-network benefits. Please note that Christine Doucette, PMHNP-BC does not participate with Medicaid or Medicare at this time.

By signing this form, I acknowledge that this form was completed accurately to the best of my knowledge, and I understand that completion of this form does not constitute a therapeutic relationship with Christine Doucette, PMHNP-BC.

Patient, or in case of minor, Parent/Guardian Name (Print)

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Month

Day

Year

Please allow up to 72 business hours for this form to be reviewed by our practice. You will be contacted via email following the processing of this request. Thank you!