In crisis or thinking about hurting yourself? Call or text 988 any time · In danger now, call 911

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MD Health Clinics, Inc.

Mind & Wellness Intake

Behavioral Health Patient Questionnaire · LMFT Counseling

“Where faith meets care, and hearts find rest.”

☎ 800.787.96591000 Quail St. #260
Newport Beach, CA 92660
In crisis or thinking about hurting yourself?
Call or text 988 (Suicide & Crisis Lifeline) any time, 24/7. In danger now? Call 911.
Please do not wait for us to read this form — reach out now.
Download the fillable intake form (PDF)

Prefer paper? Print it or fill it in on your computer, then bring it to your call. MD Health Clinics · 11 pages · fillable PDF

Your private questionnaire

Thank you for reaching out. Take your time — there are no right or wrong answers. Your answers are private and shared only with your care team, and they save as you go.