Request an Appointment - Mental Health

Still Waters Family Health Services

Please correct the errors described below.

Emergency Assistance

If you believe you have a psychiatric or medical emergency, please call 911 or the crisis hotline for your county immediately.

Centre County 1-800-643-5432 (CAN HELP)
Clearfield County 1-800-341-5040 (Clearfield Jefferson – Mental Health Crisis Intervention Services)
Clinton County 1-570-748-2262 (Lycoming-Clinton MH/ID Program)
Lycoming County 1-570-326-7895 (Lycoming-Clinton MH/ID Program)
Mifflin/Juniata Counties 1-800-929-9583 (Tri-County Crisis)
Blair County 1-814-889-2141 Choose option 1 (Blair County Department of Social Services)
National Crisis Hotline 1-800-273-8255

Client Information

First name

Last name

Email address

Phone number

Are you looking for Therapy/Counseling?

Yes No

Are you looking for Medication Management?

Yes No Unsure

Is this your first appointment?

Yes No

Date of Birth

Primary Care Physician

Your Address

Emergency Contact

(Include Phone Number & Relation)

Ethnicity

Not Hispanic/Latino Hispanic/Latino

Race

White Black/African American Other Decline

Who referred you? / How did you hear about us?

Are you currently seeing anyone for Psychiatry?

Yes No

Are you currently on any Mental Health related medications?

Yes No

If Yes, what medications are you on?

Any known Drug Allergies?

Yes No

If Yes, what drugs are you allergic to?

What would you like to discuss with the provider at your first appointment?

Anxiety

Bipolar Disorder

Depression

PTSD

Other

Please Describe

What would you like to discuss with the provider at your initial appointment?

Insurance Information

Insurance Provider

Insurance Member ID #

Insurance Group #

Who is the subscriber of your insurance?

If not you, what is their name and D.O.B?

About Your Appointment

Reason for Appointment

What is the main reason for wanting to be seen, and what would you like to discuss with the provider at your appointment?

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Emergency Assistance

If you believe you have a psychiatric or medical emergency, please call 911 or the crisis hotline for your county immediately.

Centre County 1-800-643-5432 (CAN HELP)
Clearfield County 1-800-341-5040 (Clearfield Jefferson – Mental Health Crisis Intervention Services)
Clinton County 1-570-748-2262 (Lycoming-Clinton MH/ID Program)
Lycoming County 1-570-326-7895 (Lycoming-Clinton MH/ID Program)
Mifflin/Juniata Counties 1-800-929-9583 (Tri-County Crisis)
Blair County 1-814-889-2141 Choose option 1 (Blair County Department of Social Services)
National Crisis Hotline 1-800-273-8255

Still Waters Family Health Services

(814) 205-4025
stillwatersmh.com
stillwatersfamilyhealthservices
216 North 2nd Street, Suite 5, Clearfield, PA, 16830, USA

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