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 explain reCAPTCHASubmitReset