MBM

Intake Screen

This request is not an emergency or urgent matter - I wish to proceed.

Yes No

I understand that Dr. Mefford does not treat the following conditions due to the limitations of this practice: *
Bipolar I disorder
Borderline, narcissistic, or antisocial personality disorders
Schizophrenia, Schizoaffective disorder, Paranoia, Psychosis
Substance use disorder
Frequent suicidal ideation
Psychiatric hospitalization for any reason in the past 5 years

One or more of the above conditions apply to me None of the above conditions apply to me

What is your name?

What is your date of birth?

What is your current address including city, state, and zip code?

How were you referred to me?

What are your main concerns?

Have you been diagnosed with ADHD at any time in the past? *

Yes No

If so, please list any medications or interventions that were used then

Do any family members have ADHD? *

Yes No

If you are concerned about ADHD, is there a friend, family member, coworker, or significant other who has
observed these symptoms and would be willing to fill out a brief rating scale about these symptoms?

If you are concerned about ADHD, is there evidence from work reviews, driving records, or performance
evaluations that would support symptoms of inattention, poor organization, hyperactivity, or impulsivity?

Do you currently have any medical conditions? *

Yes No

If so, please list them.

Please list all current medications and doses and over the counter products:

Have you had any serious heart conditions including chest pain or pressure, palpitations, fainting, or
congenital heart problems?

Has anyone in your family died under the age of 50 from heart-related illness or stroke? *

Yes No

Do you have any history of legal problems, including DUI's? *

Yes No

In the past three months, have you used any type of marijuana product, used recreational drugs other than
marijuana, or had more than twenty drinks per week? *

Yes No

I understand that all visits will be virtual visits performed over a real-time audio/video telepsychiatry platform.

Yes No

Michael Mefford, MD does not participate in insurance plans. I understand I am responsible for payment in
full at the time service is rendered, unless other arrangements have been made. I will be provided a
statement so I may try to get some reimbursement from my insurance company if I am eligible.
Please acknowledge that you understand this condition. *

Yes No

I will review the above information and let you know if I think we would be a good fit for one another. Please
provide an email address so that I can contact you.

Email *