New Intake Form for Medication
Evaluation and Management
How would you like to be contacted?*
Do you have a history of exposure to the following:*
Have you ever been evaluated for, or diagnosed with, any of the following:*
Please list your current mental health symptoms:*
Are you a veteran or an active member of the military?*
Do you have a history within the last 6 months of suicide attempt?*
Are you currently involved in any legal disputes?*
Are you currently in a household that is experiencing domestic violence?*
Who referred you to Key Therapy?*
Please note: Key Therapy is not able to offer 24/7 crisis services. If you are in crisis, please call 211. If you are having a mental health emergency, call 911 or go to your nearest ER.
