Request appointment | Summit Psychiatric Services

What is the primary reason you are seeking care?

Please select the option that best describes your main concern today. You can discuss additional concerns during your appointment.

What type of care are you seeking at this time?

If this is your first visit, please select “Psychiatric evaluation & medication management.”

Psychiatric evaluation & medication management Medication follow-up Second opinion Transfer of care Not sure / want to discuss

Which of the following mental health treatments or experiences apply to you? (Select all that apply)

This information helps determine whether our services are a good fit and ensures appropriate care.

Currently in therapy or counseling Previously participated in therapy or counseling Currently taking psychiatric medication Previously taken psychiatric medication Psychiatric hospitalization within the past year Psychiatric hospitalization more than one year ago Past suicide attempt or self-harm behavior History of neurologic or developmental condition (e.g., seizure disorder, TBI, autism) None of the above

Please list all current medications (psychiatric or other), including dose if known.

Have you previously been diagnosed with ADHD by a clinician?

Yes – formally diagnosed by a clinician No – never diagnosed I suspect ADHD but have never been evaluated

Are you currently prescribed any stimulant medications (Adderall, Vyvanse, Ritalin, Concerta, etc.)?

Yes No

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