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405-914-6634

info@uym-clinic.com

Welcome to Unwind Your Mind Psychiatry & Wellness.

Please take 2-3 minutes to complete this prescreen form before your visit

This will help us better understand your needs. Your answers are private and secure.

First Name

Last Name

Patients Birthday

Phone

What type of care are you looking for? (Check all that apply) * Required

Medication Management

Therapy

Both

Unsure

Are you currently taking any psychiatric medications?

Are you currently taking any psychiatric medications? If yes, please list your current medications and dose.

Have you seen a psychiatrist or therapist before?

Do you have a past diagnosis or mental health history? * Required

Depression

Anxiety

Bipolar Disorder

ADHD

PTSD

OCD

Schizophrenia

Psychosis

Easting Disorder

Substance Abuse

None/Prefer not to say

Other

Other, Pleas describe diagnosis or mental health history.

Are you cirrently in crisi or having thoughts of harming yourself or others?

If YES, please call 911, visit the ER, or call/text 988 immediately.)

Is there anything else you'd like us to know before your appointment?

I agree to the terms & conditions

Thanks for submitting!

1501 S. Ranchwood Blvd, Suite 203, Yukon, OK 73099

Tel: 405-914-6634

Fax: 405-914-6693

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