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 Welcome to Psynoptic

We're Glad You're Here!

To get started, please take a moment to fill out our brief assessment form to help us understand your needs and how we can best support you. Rest assured, your responses are protected with the highest standards of privacy and security.

 

Once we receive and review your information, one of our dedicated team members will reach out to discuss the next steps and how we can assist you on your path to wellness.

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This form is intended for adults to complete; if you are seeking mental health care for a minor, please have a parent or guardian fill out this form using the child’s information.

Patient Assessment

Gender
Date of Birth
Month
Day
Year
Are you seeking a psychiatric evaluation for any of the following reasons? Select all that apply.
Have you been diagnosed with any of the following conditions? Select all that apply.
Have you been hospitalized for any psychiatric or mental health reason in the previous twelve (12) months?
No
Yes
How often have you had suicidal thoughts in the last six (6) months?
Never
About once a month
About weekly
Almost daily
Daily
Have you engaged in self-harm or other self-injurious behaviors in the last six (6) months?
No
Yes
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