Request appointment | NEALCore Mental Health Solutions, LLC

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

Are you currently experiencing a mental health emergency, having thoughts of suicide or self-harm, or having thoughts of harming someone else?

This form is not monitored for emergencies. If you are in immediate danger or need emergency assistance, call 911 or go to the nearest emergency department. You may also call or text 988 for the Suicide & Crisis Lifeline.

Yes No

Are you currently taking any psychiatric medications? If yes, please list the medication name(s) and dose(s), if known.

Please include medications prescribed for mental health, ADHD, sleep, or substance use treatment. If you are not currently taking any psychiatric medications, enter “None.”

Limited to 600 characters

Are you seeking evaluation or treatment that may involve a controlled medication, such as a stimulant medication for ADHD or a benzodiazepine for anxiety?

Requesting a specific medication does not guarantee that it will be prescribed. Medication recommendations are based on a comprehensive psychiatric evaluation, clinical appropriateness, and applicable prescribing requirements.

Yes No Unsure

Are you seeking treatment related to alcohol or substance use, including Medication-Assisted Treatment (MAT)?

This may include concerns related to alcohol, opioids, stimulants, or other substances, as well as treatment with medications such as buprenorphine.

Yes No Unsure

What are the primary concerns you would like addressed?

Select the concern(s) that best describe what you would like to address. A formal diagnosis, when appropriate, will be determined after a comprehensive psychiatric evaluation.

Are you currently receiving psychiatric medication management from another healthcare provider?

If you are transferring psychiatric care, NEALCore Mental Health Solutions may request records from your current or previous provider before or after your initial evaluation.

Yes No

Have you received emergency or inpatient psychiatric care within the past 6 months?

This includes psychiatric hospitalization, an emergency department visit for a mental health concern, or treatment in an inpatient psychiatric facility. A “Yes” response does not automatically prevent you from receiving services.

Yes No

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