Clinical Info
How were you referred to me? *
What medications are you currently taking? Please list the name, dosage and directions. Please note efficacy and tolerance for your current medication regiment. *
If you are currently on medications, who is currently prescribing your current medications? Why are looking to find another prescriber? *
Do you have a current therapist or prescribing physician? If so, who? *
Have you ever been hospitalized for mental health? If so, when, where, and for what? *
Please describe your symptoms and the reason you are reaching out to The Kulkarni Group. *
How long have you been struggling with these symptoms? *
If the patient is a minor, who else lives in the home with the patient? *
If the patient is a minor, and the parents are divorced, which parent/guardian has authority to make decisions in medical care? *
Scheduling Info Were you referred to a specific provider in the practice? If so, who? *
Some of our providers see patients in office and telehealth, some do not. Do you prefer to see the provider in person or via telehealth? *
Please list the best days and times for our Intake Coordinator to contact you via telephone. *
What is your Member ID? *
What is your Group Number? *
Policy Holder Name, Date of Birth and relationship to the patient? *
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