Patient Forms New Patient Information Name* Date of Birth* Current Age* Partner Status* Race* GenderSelect valuemalefemaleother Preferred pronounsSelect valuehe/himshe/herthey/themother Current medications, doses, and when each is due to run out* Mailing address* City* State Zip* Cell Phone* Home Phone* Is it OK to leave a message?*Select valueYesNo Email* Emergency Contact* Emergency Contact Relationship* Emergency Contact Cell Phone* Emergency Contact Email Address* Pharmacy name, location, and phone number* Lab you use for blood work* Name of your medical doctor* Type of Doctor*Select valueInternal MedicineFamily Medicine Names of other medical specialists you see* Name of your therapist (if you have one)* Who referred you to WPH?*PLEASE ANSWER AND EXPLAIN IF NEEDED Active suicidal thoughtsYesNo Suicidal thoughts explain Active psychotic thoughtsYesNo Psychotic thoughts explain Active substance abuseYesNo Substance abuse explain Active legal issuesYesNo Legal issues explainSubmitReset