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Resonance Psychiatry

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Reason for care

Select date & time

1 Appointment info

2 Prescreener

Reason for care

3 Contact information

What brings you to seek psychiatric care right now?

Limited to 600 characters

What kind of support are you looking for?

Medication management Therapy/counseling Both Not sure

Current diagnoses (check all that apply):

Depression Anxiety PTSD ADHD Bipolar disorder OCD Personality disorder Eating disorder Substance use disorder None/unsure Other

Are you currently taking any psychiatric medications?

Yes No

If you are taking any psychiatric medications, please list them:

Limited to 600 characters

Have you worked with a psychiatrist or a psychiatric NP in the past?

Yes No

If yes, why are you seeking a new provider?

Are you currently in therapy or willing to work with a therapist?

Yes, currently in therapy Not currently, but open to it No

In the past year, have you visited the ER or a crisis center for psychiatric reasons?

No 1-2 times 3 or more times

Are you currently prescribed a controlled medication to treat a psychiatric condition?

If yes, please list the medication name at the end of the questionnaire

Yes, a benzodiazepine Yes, a sedative hypnotic Yes, a stimulant No

Are you currently experiencing suicidal thoughts, intent, or a plan?

Yes No

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

Resonance Psychiatry

Toms River, NJ

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THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.