Request appointment | CalmPath Mental Health, Walsh Psychiatric Service, LLC (d/b/a)

What concerns would you like help with?

(Check all that apply)

Anxiety or Panic Attention / Focus concerns (ADHD) Depression or Mood concerns Grief Medication review or adjustment Sleep concerns Suicidal or Self-harming concerns Trauma or Stress-related concerns Other (optional) ___________________________

Where will you be physically located during appointments?

(This helps ensure telehealth services are provided appropriately.)

Illinois Another state (please specify) ____________________________

Type of mental health treatment receiving currently or in the past?

Had therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

What type of care are you seeking?

Note: New patients typically begin with a comprehensive psychiatric evaluation.

Psychiatric evaluation & medication management Medication consultation / second opinion Not sure would like guidance

Have you received mental health treatment in the past?

This helps us understand your background and prepare appropriately for your visit.

No prior treatment Therapy only Medication management only Therapy and medication management Prefer to discuss during the visit Hospitalized for mental illness

Are you currently experiencing any urgent safety concerns (such as thoughts of harming yourself or others)?

(If you are in immediate danger, please call 911 or go to the nearest emergency room.)

No. Yes - thoughts of harming myself Yes - thoughts of harming others Yes - another urgent concern

Is there anything important you’d like me to know before our first visit?

(Optional) _____________________________________

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