New Patient Questionnaire Δ Step 1 of 205%EmailThis field is for validation purposes and should be left unchanged.Are you the prospective patient?* Yes NoPlease have your loved one fill out the questionnaire personally. Dr.Kraker feels strongly that her patients are personally motivated for treatment.Are you at least 18 years old?* Yes NoThank you for your interest. Dr. Kraker is only board-certified in adult psychiatry and unable to care for minors. Please seek care with a child and adolescent psychiatrist.Please provide your full name.*Please provide your email address.* Please provide the best phone number to reach you.*What is your age?Reason For Visit?AnxietyMood DisorderEating DisorderAddictionFocus + Brain OptimizationIntegrative PsychiatryLife Transition / StressPersonalized Executive WellnessRelationship DifficultiesTraumaWalsh ProtocolWomen's Reproductive HealthPlease elaborate on your selection above:How many previous psychiatric hospitalizations have you had?0123 or moreAre you interested in possibly starting, changing or tapering medication?Starting MedicationChanging MedicationTapering MedicationNone of the abovePlease list both your current and past medications, including doses and when medications were started and discontinued.Are you willing to have lab (blood) work done to get to the root cause of your underlying symptoms? Yes NoAre you willing to a genetic test (23 & Me or Genomind) to get to the root cause of your underlying symptoms? Yes NoDo you believe that pharmaceutical medication is necessary in your treatment?YesNoI'm not sureDo you have diagnosed medical problems? Please list them.Have you consulted with a functional medicine or holistic provider before? Yes NoWhy are you seeking a holistic approach to your mental health and wellness? Please provide details.Do you plan to continue seeing any doctors or health care providers while a patient? Yes NoAre you currently ready and open to begin implementing lifestyle and dietary changes?Please describe your daily nutritional habits including meals, snacks and beverages:Do you have a religious or spiritual practice? Do you meditate, sit, pray?Do you smoke?NicotineMarijuanaBothNeitherPlease confirm that you are aware that Dr. Kraker does NOT accept any insurance. She functions only as an out of network provider, and will provide a super bill with the appropriate diagnostic and procedural codes for your care. As you may know, email and form submissions are not an entirely secure medium, therefore the confidentiality of messages can not be guaranteed. Please use discretion when sending information that is sensitive in nature. It is unlikely Dr. Kraker has an immediate opening — would you like to add your name to her waitlist? Yes NoJoin Dr. Kraker's growing community of people looking for a better approach to mental health? Yes
