Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Are you currently prescribed any benzodiazepine medications?(Examples include both brand and generic names) *

Common benzodiazepines include: Alprazolam (Xanax), Clonazepam (Klonopin), Diazepam (Valium), Lorazepam (Ativan), Temazepam (Restoril), Chlordiazepoxide (Librium), Triazolam (Halcion), Oxazepam (Serax), Midazolam

No

Yes

Reason for Appointment *

Court Ordered

Diagnosis

Medication Management

Psychotherapy

Recent Hospitalization

Treatment for drug/alcohol abuse

Other

Disclaimer *

Clear Psychiatric Services respects your privacy. Please be aware that phone and email communications may not be secure and could potentially be intercepted by unauthorized parties. By contacting us via email or phone, you agree to these communication methods and understand the inherent risks involved. If you prefer to discuss sensitive information in a more secure manner, please request access to our secure messaging alternative. Clear Psychiatric Services will not share your contact information with third parties without your consent, except as required by law. Our team strives to respond to emails and phone calls promptly, but please allow up to 48 business hours. If you are experiencing a mental health crisis, call or text 988 to connect with the Suicide & Crisis Lifeline. If you are experiencing a life-threatening emergency, dial 911 or go to your nearest emergency department.

I Agree