Patient Intake Form


Welcome, we are delighted to meet you!

Thank you for considering care with Dr. Nathan. This brief screening helps ensure her practice is the right fit for your needs before moving forward. Dr. Nathan values your time and wants to make this process as clear and supportive as possible. Her approach blends traditional psychiatry with mindfulness, compassion, and deep therapeutic connection. To help you decide whether her services align with what you’re seeking, the following information outlines how her practice operates. Please review each item and confirm your understanding so we can determine next steps together. You will be asked to read and confirm your understanding and agreement to each of the following:

This form and any subsequent introductory call or screening form is solely to determine whether Dr. Nathan’s services are a good fit and does not establish a doctor–patient relationship or include medical advice.

Name:

Gender *

Phone:

Email * ​​​​​​

Date of Birth * ​​​​​​​

City

State

Insurance or Cash Pay:

If using insurance, who is your provider?:

Please note-Heart Centered Psychiatry does not currently accept Medicare/Medicaid/Prescribe controlled substances

Please select all boxes that apply to you:

If you checked yes on any boxes, please explain with dates:

Are you currently taking any prescription medications?

If so, please list:

What are your reasons for seeking care?

Please explain your main concerns:

Is there anything else you feel that Dr. Nathan should know at this time?

What To Expect Next

  • All submitted forms are reviewed by our team to determine whether Dr. Nathan’s practice is an appropriate fit for your needs. Submission of this form does not guarantee acceptance into care.
  • A member of our team will contact you within 48 business hours to discuss next steps, including availability, fees, and scheduling. Please note that business hours do not include weekends or holidays.



Important Safety & Care Information

Dr. Nathan’s practice is not an emergency service and does not provide crisis intervention.

  • If you are experiencing a medical or psychiatric emergency, please call 911 or go to the nearest emergency room.
  • If you are experiencing thoughts of self-harm or suicide, you may call or text 988, the Suicide & Crisis Lifeline, available 24/7.


Completion of this screening form, and any related phone calls or communications, does not establish a physician–patient relationship and does not constitute medical advice, diagnosis, or treatment.

Thank you for taking the time to complete this screening. We appreciate your thoughtfulness in helping us ensure the best possible match for care.

By submitting this form, you confirm that the information you have provided above is true, complete, and accurate to the best of your knowledge. [Please sign and be sure to click the "Submit Form" button]