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Inderpreet Dhillon MD, MBA
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Intake form
Help us serve you better
Name
*
Email address
*
What is your date of birth?
What is your gender?
Select
Male
Female
Non-binary
Prefer not to say
What is your primary reason for seeking psychiatric care?
Please select at least one option.
Anxiety
Depression
ADHD
Bipolar Disorder
PTSD
Have you received psychiatric treatment before?
Select
Yes
No
If yes, please specify the type of treatment received.
Are you currently taking any medications?
Select
Yes
No
If yes, please list the medications you are currently taking.
Do you have any allergies?
Select
Yes
No
If yes, please specify the allergies.
What is your preferred method of communication?
Select
Email
Phone
Video Call
Do you have any family history of mental health issues?
Select
Yes
No
If yes, please provide details.
Additional questions or comments
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