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Patient Forms · New Jersey

Register online before your first visit.

Complete your full intake online before your first appointment — personal, insurance, and psychiatric history in one secure form. It helps our clinical team prepare and means less paperwork on the day of your visit.

Secure & HIPAA-compliant 12 short sections About 10–15 minutes
Person signing intake paperwork at a desk, the first step toward starting psychiatric care
1 formcovers your full new-patient intake
What happens after you submit

Your Information Goes Straight to Our Clinical Team

Nothing about completing this form schedules your visit automatically — a real person reviews what you send and follows up directly.

  1. Our clinical team reviews your intake, including your medication list and psychiatric background, before you're ever seen.
  2. We call or email you — usually within one business day — to verify your insurance coverage and answer any questions.
  3. We schedule your first appointment with Zainab Ali, PA-C, by video or at our Hoboken office, at a time that works for you.
Before you register

What to Have on Hand

Having a few things ready makes registration faster and helps us prepare for your first appointment. You don't need your insurance card or a photo ID to complete this form — we'll verify coverage by phone before your visit.

  • Current medication list, including dosages
  • Any previous psychiatric diagnoses or treatment history
  • Your pharmacy's name and location, if you'd like prescriptions sent there

See our first visit guide for the full list of what to expect, or our insurance page to check your coverage before you register.

Get started

New Patient Registration

Complete this form and our compassionate team will contact you within one business day to verify your insurance and schedule your first appointment. Required fields are marked with an asterisk — everything else can be left blank if it doesn't apply to you.

1 Personal Information

2 Contact Information

3 Health Insurance

4 Reason for Visit

e.g. "Anxiety and trouble sleeping for the last 6 months"
If you'd like us to coordinate with your other providers, list name, specialty, and location.

5 Medical History

Leave any of these blank if they don't apply to you.

6 Pharmacy Preferences

7 Lifestyle

Helps us understand health risk factors. Leave any of these blank if they don't apply to you.

8 Mental Health Screening

Over the last 2 weeks, how often have you been bothered by the following?

If you're having thoughts of harming yourself right now, please call or text 988 (Suicide & Crisis Lifeline) or go to your nearest emergency room. See our crisis resources page.

9 Psychiatric Background

Have you been given any psychiatric diagnoses? If yes, list them.
Any past medications that caused side effects or didn't work well?
Psychiatrists, therapists, or counselors you've seen, or are seeing now.

10 Additional Information

11 Consent & Signature

Our Privacy Policy and Terms of Service explain how we handle your information and our appointment policies.

Per the ESIGN Act of 2000, your typed name is as legally binding as a handwritten signature.

12 How Did You Find Us?

You can also call us directly at (908) 450-7002 for immediate assistance.

Thank you! Your registration has been received and is on its way to our clinical team. We'll reach out within one business day to verify your insurance and schedule your first appointment.
Submitting… Please wait while we process your information.