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NEW PATIENT SURVEY - 2015 Version

GENERAL INFORMATION

We want to ask you for some general information about you. We use this information to set up your medical record. Everything that you tell us is confidential. 
Hello! Thank you very much for taking the time to complete this questionnaire. The information that you provide is stored on a secure, encrypted, password-protected website that is only accessible by Gateway clinic treatment providers. Please be as thorough and detailed as possible in your answers as this information is very important for our evaluation and treatment planning.

The survey will take you about one to two hours to complete. We encourage you to take a break as necessary by clicking on the "Save and Continue Later" link at the top of each page. Once you reach the last page, you will no longer have this option and will be forced to submit the survey so be careful to not jump too far ahead.

Thank you again and we look forward to meeting with you very soon!

Peter Forster, MD and the Gateway Psychiatric Services Team
Hello! Thank you very much for taking the time to complete this questionnaire. The information that you provide is stored on a secure, encrypted, password-protected website that is only accessible by Gateway clinic treatment providers. Please be as thorough and detailed as possible in your answers as this information is very important for our evaluation and treatment planning.

The survey will take you about one to two hours to complete. We encourage you to take a break as necessary by clicking on the "Save and Continue Later" link at the top of each page. Once you reach the last page, you will no longer have this option and will be forced to submit the survey so be careful to not jump too far ahead.

Thank you again and we look forward to meeting with you very soon!

Peter Forster, MD and the Gateway Psychiatric Services Team
Contact Information
calendar
Do you Identify as Hispanic or Latino?
Telephone Numbers *This question is required.Please add all your telephone numbers
Space Cell Telephone/Beeper
Home
Work
Mobile
Other (specify
This question requires a valid email address.
Is it Ok to contact you via email?
Person to be contacted in case of an emergency *This question is required.
Space Cell Details
Name
Relationship
Home Phone
Work Phone