Request appointment | Pax Mentis Psychiatry

Important Notice: This form is not monitored in real time and is not intended for emergencies. If you are in crisis, having thoughts of harming yourself or others, or feel unsafe, please call 988, 911, or go to the nearest emergency department immediately. Pax Mentis Psychiatry is not able to provide care for individuals who are experiencing a psychiatric emergency or who feel unable to keep themselves safe.

What is the reason for seeking care?

What kind of care is being sought?

Preventive/Maintenance of Mental Health Medication Management Integrative mental health care Not sure Other

What mental health concerns or treatment have occurred in the past?

Currently in psychotherapy Previously in psychotherapy Currently taking psychiatric medication(s) Took psychiatric medication(s) in the past Recent psychiatric hospitalization (within the past 30 days) Known neurologic or genetic disorder Attempted suicide in the past Recently received treatment for substance use disorder (within the past 30 days) None of the above

What type of service are you seeking?

In the past 30 days, have you used any of the following substances? (Select all that apply)

Are you seeking treatment for opioid use disorder or Suboxone/buprenorphine management?

Please note: Pax Mentis Psychiatry does not offer medication-assisted treatment (MAT) for opioid use disorder, including Suboxone/buprenorphine.

Yes No

How would you describe your substance use?

Pax Mentis Psychiatry does not provide emergency or crisis services. Do you understand that you must call 988/911 or go to an ER for emergencies?

Yes No

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