New Patient Questionnaire

Are you the prospective patient?*
- Yes
- No
Please 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
- No
Thank 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 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
- No

Are you willing to a genetic test (23 & Me or Genomind) to get to the root cause of your underlying symptoms?
- Yes
- No

Have you consulted with a functional medicine or holistic provider before?
- Yes
- No

Why 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
- No

Are you currently ready and open to begin implementing lifestyle and dietary changes?

Please describe your daily nutritional habits including meals, snacks and beverages:

Please 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
- No
Join Dr. Kraker's growing community of people looking for a better approach to mental health?
- Yes
Name
This field is for validation purposes and should be left unchanged.