Dr. David Tharp, board certified psychiatrist and counselor, and the staff at Stonebriar Psychiatric Services are ready to meet your counseling and psychiatric needs.  Offering a
broad range of services, including evaluation,  psychotherapy, counseling and medication management.  Call us if you are struggling with depression, anxiety, obsessive
compulsive disorder, eating disorders, ADHD, family or marital issues, compulsive behaviors such as sexual addiction, post-traumatic stress related to past abuse, or self esteem
issues.  Service area:  Frisco, Plano, McKinney, Allen, Richardson, Prosper, Celina, Denton, Collin County, Dallas, Fairview, Murphy, Carrollton, Anna, Melissa.

Stonebriar Psychiatric Services, P.A.         Patient Intake Form for Individual (adult, adolescent or child)    

To be completed by patient (not third parties unless patient is under 18 years of age)

Boxes regarding your concerns and history will expand to accommodate your answers.
Please provide as much information as possible in the dialog boxes.  
Patient Name:
Person completing form if
not Patient (if pt. under 18):
Date:  
Home Phone:
Cell Phone
Occupation:
Work Phone:
E-Mail Address:
Date of Birth:
Address:
How did you hear about us?
What prompted you to contact us at this time?
What is bothering you?
Check all of the symptoms below that are causing you problems.  If there is a space next to the symptom, please fill in how (ie.  for drug issues, what drug(s), for thoughts
of hurting self or others - explain,etc.)
Increased appetite
Obsessive thoughts
Depression
Increased sleep
Alcohol issues
Decreased appetite
Mood swings
Compulsive actions
Decreased sleep
Drug issues
Binge
Anxiety
Can't concentrate/focus
Can't fall asleep
Thoughts of
hurting self or
others
Panic attack
Frequent waking
History of ADHD
Purge
Pornography
Restrict food intake
Difficulty being
in public places
Early waking
Excessive exercise
History of trauma/abuse
Current/Previous psychiatric treatment:
Current/Previous psychotropic medications:
Does this include legal involvement?(explain)
Is there anything else that is important to
you that you want to tell us?
I understand that Stonebriar Psychiatric Services does not accept insurance
Because we hold a large block of time for your evaluation, a MINIMUM of 48 business hours’ notice is required for any changes to your appointment time once you
have scheduled.
New patient forms are available on our website.  Simply select the type of appointment you are requesting and download all forms under that heading.  You may fax
the completed forms to us at 972-852-1812, which will allow us to process them prior to your arrival, saving you time on the day of the appointment.  You may
also bring them with you to the scheduled evaluation and we will process them upon your arrival.
Stonebriar Psychiatric Services, P.A.
972-335-2430
3550 Parkwood Blvd.  Suite 705
Frisco, TX  75034