NEW PATIENT SURVEY

GENERAL INFORMATION

Hello and Welcome!

Let's gather some general information about you. We will use this information to set up your medical record.

The information that you provide is stored on a secure, encrypted, password-protected website that is only accessible by Gateway clinic treatment providers. Please be as thorough and detailed as possible in your answers as this information is very important for our evaluation and treatment planning.

The complete survey will take you about one to two hours to complete. We encourage you to take a break as necessary by clicking on the "Save and Continue Later" link at the top of each page. Once you reach the last page, you will no longer have this option and will be forced to submit the survey so be careful to not jump too far ahead.

We look forward to meeting with you very soon!

Peter Forster, MD and the Gateway Psychiatric Services Team

Contact Information

First Name

Last Name

Birth Date

calendar

Age

Address *This question is required.

City

State

Zip

Country

Who do you live with?

Telephone Numbers *This question is required.Please add all your telephone numbers

Space Cell	Telephone/Beeper
Home	Telephone/Beeper
Work	Telephone/Beeper
Mobile	Telephone/Beeper
Other (specify	Telephone/Beeper

Email Address This question requires a valid email address.

Is it Ok to contact you via email?

Person to be contacted in case of an emergency *This question is required.

Space Cell	Details
Name	Details
Relationship	Details
Home Phone	Details
Work Phone	Details

How did you hear about Gateway Psychiatric Services?