patient demographics

"*" indicates required fields

PATIENT DEMOGRAPHICS

Please complete all required information and submit.

Legal First Name*

Middle name

Legal Last Name*

Preferred Name/Nickname

Sex Assigned at Birth*

Male

Female

Gender Identity

Date Of Birth*

MM slash DD slash YYYY

Address*

Street Address City State ZIP Code

Email*

Phone*

Do you have any friends or family receiving care at Certus? If yes, please include their name, relation to you, and the provider they are seeing. Certus Policy prohibits a care provider from seeing multiple family members.*

Reason for this appointment:*

Establishing new care

Relocation

Seeking a second opinion

Provider change (due to office closing, provider retirement, etc.)

Other

Name of previous mental health care provider, if applicable

First Last

Address

City State / Province / Region

Date last seen

MM slash DD slash YYYY

Select any previous diagnosis (select all that apply)

ADHD

Anxiety

Bipolar/Mood Disorder

Depression

PTSD

OCD

If previous diagnosis is not listed, please describe

Select any previous treatment (select all that apply)

ECT

TMS

Ketamine

IOP

PHP

Inpatient

List month and year of previous treatment

If previous treatment not listed above, please specify and include month and year of that treatment

Type of care you are seeking: Please choose the option(s) that best describes the type of are you believe you need.*

Psychiatric Care / Medication Management

Counseling / Psychotherapy

Ketamine

TMS

ADHD Assessment

EMDR / Alpha Stim / BrainSpotting

Other (please elaborate below)

If "other" please elaborate below

Significant history of substance abuse*

Yes

If yes, list substance(s)

Significant aggressive behavior/sexual misconduct*

Yes

Insurance or Self-Pay*

Note: We do not accept Medicaid at this time.

I have medical insurance.

I will be paying.

Insurance Provider

Other Insurance

Insurance Card Front*

Max. file size: 1 GB.

Insurance Card Back*

Max. file size: 1 GB.

Photo ID Front*

Max. file size: 1 GB.

Photo ID Back*

Max. file size: 1 GB.

Parent or Guardian*

I am making appointment for a child (17 or younger) in my care.

I am making an appointment for myself

I am making an appointment for an adult in my care (Guardianship/POA paperwork must be brought to first appointment)

Add Emergency Contact*

First Last

Phone*

Relation To You*

Primary care provider & practice name (If you don't have one, leave blank)

Preferred pharmacy name & address

List all allergies and sensitivities to food & medications (If you don't have any, please indicate "None" in the first box. Click the "+" to add to your list.)*

List all over-the-counter and prescribed medications, dosages, and directions (click the "+" to add to your list.)*

Feel free to include any additional information you would like your care team to know about you.

How did you hear about Certus Psychiatry?

This field is for validation purposes and should be left unchanged.

Find balance and recovery here.

Winston-Salem Office

1255 Creekshire Way
(between Brixx and Firebirds)

Two Convenient
Locations!

833.701.3111

Raleigh Office

1350 Sunday Drive
Suite 101

patient demographics