Patient Intake Form

University Psychiatric Practice, Inc.

New Patient Intake Form

Please fill out the form below and submit. A member of our team will reach out to you shortly. Thank you!

Patient Intake Form

Fill in the fields of this form with your information and a representative will respond shortly.

Name(Required)

First Last

Date of Birth:(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

(XXX) XXX-XXX

Best time to contact you:(Required)

Morning

Afternoon

No Preference

Primary Care Physician/ Practice:(Required)

Insurance:(Required)

Were you referred to UPP?(Required)

Yes

Other

Reason for seeking psychiatric care?(Required)

Are you currently taking psychiatric medications?(Required)

Who is prescribing?(Required)

Do you have a therapist?(Required)

Therapist Name (If applicable):(Required)

Please, have your Primary Care Physician and Therapist fax over your referral information (last office note) to us at (716) 835-0396. Indicate below if there is any other information you would like us to know:(Required)

CAPTCHA

716.835.1246

716.835.1246

University Psychiatric Practice, Inc.

New Patient Intake Form

Patient Intake Form

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UBMD Psychiatry

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