Intake Form

Please Print and Email to alpinepsych@gmail.com

Information to know before onboarding with Alpine Psychiatry:

  1. If you have had any inpatient hospitalizations within the past 12 months, Alpine cannot provide the level of care that you may need and will be unable to take you on as a patient.

  2. Alpine will not prescribe benzodiazepine.  Benzos should be prescribed and monitored by your PCP or another provider.

  3. Alpine does not fill out any disability paperwork until you are an established patient for 6 months.

  4. Alpine does not prescribe any medication assisted treatment for substance use disorder such as suboxone.

  5. The first evaluation must be held in person at our King of Prussia office.  Depending on the provider, you may be able to hold your first evaluation virtually.

  6. You must have an appointment in order to receive any refills.  Please discuss this with the provider.  Controlled substances will require a monthly appointment for refills. 

  7. All communications will be done through our texting software - Klara. This includes ALL paperwork that is required during the intake process & any paperwork that is required when you are an existing patient.  Any patient 14 years of age and older must have their own Klara account so we can contact them also.  Once the form below is completed, we will text you at your cell phone number provided to complete the intake process.  The text will come from Alpine Psychiatry. 

  8. A credit card is required to be held on file for automatic charging of copays and other possible charges.  We will request this info from you later in the intake process through Klara. 

  9. There is a 24 hour notice of cancellation policy and a no call no show policy.  If you don’t cancel any and all appointments within a full 24 (business) hours, you will be charged a fee of $175 for a new eval appointment and $75 for an existing patient follow up appointment.  The same applies for any no call no show appointments.  Your credit card held on file will be automatically charged.

***By submitting your answers to this form below, you are agreeing to comply to and understand the above policies and procedure of Alpine Psychiatry.  

1 - How did you hear about our practice?


2 - Patient Name & Date of Birth:


3 - Patient Gender at Birth, Gender Identity & pronouns:


4 - Patient Cell #, Email Address & Home Address. (14 and older):


5 - Parent's or Emergency Contact’s Name, Cell, Email Address & Home Address:


6 - Diagnoses (or what have you been treated for & for how long):


7 - Current Therapist/Counselor.  List name and email address: 


8 - Current medications w/dose & frequency AND past failed meds:


9 - Drug & Food Allergies (List reactions):


10 - Pharmacy name, phone number & Address: 


11 - A brief statement of what is going on with the patient.  Main reason why you are seeking services: Symptoms, thoughts, stability & behaviors: 


  1. Is there is any suicidal or homicidal ideation? 
  2. Any history of eating disorders? 
  3. History of drug & alcohol abuse?


12 – Have you had an inpatient hospitalization or intensive outpatient treatment (IOP) in the past?  If so, please list admit and discharge dates for all stays in the past 3 years.  If none, please state none. 


13 - Additional comments - for example, any brief social or family history that you may feel would be helpful for the provider. 


  1. Occupation or school.

14 – Front & Back of Insurance Card – Once you complete this form, we will text you to request a picture of the front and back of your insurance card.  But for now, please provide us with the information below:

  1. ID Number - 
  2. Name of Patient AND Policy holder - 
  3. Date of birth for patient AND Policy holder -
  4. Gender of Patient AND Policy holder -
  5. Zip code of Patient AND Policy holder -