Name of prospective patient *

First Name

Last Name

Date of birth of prospective patient *

MM

DD

YYYY

Phone *

(###)

###

####

Current symptoms

Select all that apply

Depression

Anxiety

Attention and concentration difficulties

Mania or bipolar disorder

Hallucinations or psychosis

Substance use

Oppositional behavior

Violence or destruction of property

Suicidality

Homicidality

Self-injury

Trauma

Eating disorder

Difficulties with social interactions

Relationship problems

Intellectual disability

Learning disabilities

Tics

Autism

Other

What do you hope Dr. Ross can provide for you? *

Select all that apply

Medication management

Psychotherapy

Second opinion consultation

Other