Quietside Psychiatry | SimplePractice

Reason for care

In a few short sentences, what is the reason for seeking care?

To make sure this practice is the right fit, please read the following carefully before continuing. This practice is not able to serve individuals who meet any of the following criteria: 1. Hearing voices or seeing things that others don't. 2. Feeling disconnected from reality or severely confused. 3.Psychiatric hospitalization or suicide attempt in the past 12 months. 4. Severe substance use requiring detox or rehab. 5. Court-ordered or legal evaluations or documentation. 6. Disability evaluations or documentation. 7.Suicidal thoughts or thoughts of hurting others. Do any of the above apply to you?

This practice is not a crisis service and does not provide crisis services or after-hours monitoring. If any of the above apply to you, please do not continue this form — this practice is not the right fit at this time. If you need immediate support, call or text 988, call 911, or go to your nearest emergency department.

None of the above apply to me — I understand this practice is not be the right fit if any of these apply.

Do you have reliable internet and a private space for video appointments?

Yes No

Do you currently have a primary care provider (PCP)? If no, please note you will be asked to establish care with a PCP to support safe and comprehensive treatment.

yes no

Do you currently have a psychiatrist or psychiatric nurse practitioner managing your psychiatric medications? If yes, please describe your situation and reason for seeking care elsewhere. If no, please write N/A.

Please list current prescribed psychiatric medications-------reason for taking------and dose:

Please list current medications/reason for taking/dose: if none, please write N/A

Please note, a full psychiatric evaluation is required for all new patients. Current psychiatric medications, including controlled medications such as stimulants and benzodiazepines, will not automatically be continued — and medications that have worked for you in the past are not guaranteed to be prescribed. All prescribing decisions are based solely on the results of your evaluation.

I understand and agree to the above

Submitting this form is an inquiry only and does not establish a provider-patient relationship. A provider-patient relationship is only established upon completion of a full evaluation and mutual agreement by both the patient and provider to proceed with ongoing care.

I understand and agree to the above

Client Preferences

Thank you for contacting Quietside Psychiatry. Your information will be reviewed and if this practice appears to be a good fit, you will receive a portal invite via email. Please check your email for the link. All communication is conducted through the portal for security.

Do you consent to the use of AI in the delivery of your care?

Your clinician may use AI tools (such as using AI to generate an intake summary) to help support your care. Your information is protected under HIPAA and anything generated by AI is always reviewed by your clinician. AI does not make decisions about your care. You can withdraw this consent at any time by contacting your provider without it impacting the care you receive.

Yes No