Questionnaires

ATTENTION NEW PATIENTS:

The following providers are available for new patient appointments:

Nwamaka Emeruem, DNP, APRN, MBA, FNP, PMHNP
Ebere Ejike-Ilechukwu APRN, MSN, PMHNP-BC
Lilian Okere, APRN, RN, BSN

Please follow all the steps to complete the new patient intake process:
STEP 1. Please select one of the options below (based on the patient’s age) for the set of forms you need
to fill out. You are required to answer all of the forms and all of the questions within the form. Please
make sure to wait for the “Thank you” response after submission to avoid any errors.

New Patient Intake Form

Adult (18+)

Greetings from @Ease Psychiatry!

Kindly complete all the forms below. You are also required to send us a copy of your insurance (front and back) as well as any valid ID through email. Kindly call the office as soon as you finish the paperwork.

Adult Questionnaires

Adult ADHD Self-Report Scale

Should you encounter any difficulties with the forms, please let us know by calling the office. Our staff would be happy to assist you.

Teen (11-17)

Greetings from @Ease Psychiatry!

Kindly complete all the forms below. You are also required to send us a copy of your insurance (front and back) as well as any valid ID through email. Kindly call the office as soon as you finish the paperwork.

SNAP-IV Teacher and Parent Rating Scale

Teen Questionnaire

Should you encounter any difficulties with the forms, please let us know by calling the office. Our staff would be happy to assist you.

Child (8-11)

Greetings from @Ease Psychiatry!

Kindly complete all the forms below. You are also required to send us a copy of your insurance (front and back) as well as any valid ID through email. Kindly call the office as soon as you finish the paperwork.

Child Anxiety Related Disorders

SNAP-IV Teacher and Parent Rating Scale

Short Mood and Feelings Questionnaire

STEP 2. Please send a clear copy of the following IDs (front and back):
Insurance ID
Any valid ID

STEP 3. Call the office once done with Steps 1 and 2 to confirm receipt of forms and IDs. You will be
provided a schedule once all of the requirements have been successfully received.
Eyes Here!
• All new patients and re-established patients are required to complete the new patient intake
process. Steps are provided above.
• If you have difficulty with the steps for the new patient intake process, please call the office for
further assistance.
• If you are unable to answer the forms online, please call the office for more options.
• We are very strict with the intake process, if any forms or IDs are missing, you will need to
answer and/or send the forms and IDs again.
• If you have any questions or concerns, please call the office and an office staff will be happy to
assist you.

Thank you for your understanding and cooperation!

@Ease Psychiatry

Questionnaires

ATTENTION NEW PATIENTS:

Adult (18+)

Greetings from @Ease Psychiatry!Kindly complete all the forms below. You are also required to send us a copy of your insurance (front and back) as well as any valid ID through email. Kindly call the office as soon as you finish the paperwork.

Should you encounter any difficulties with the forms, please let us know by calling the office. Our staff would be happy to assist you.

Teen (11-17)

Greetings from @Ease Psychiatry!Kindly complete all the forms below. You are also required to send us a copy of your insurance (front and back) as well as any valid ID through email. Kindly call the office as soon as you finish the paperwork.

Should you encounter any difficulties with the forms, please let us know by calling the office. Our staff would be happy to assist you.

Child (8-11)

Greetings from @Ease Psychiatry!Kindly complete all the forms below. You are also required to send us a copy of your insurance (front and back) as well as any valid ID through email. Kindly call the office as soon as you finish the paperwork.

Should you encounter any difficulties with the forms, please let us know by calling the office. Our staff would be happy to assist you.

Greetings from @Ease Psychiatry!

Kindly complete all the forms below. You are also required to send us a copy of your insurance (front and back) as well as any valid ID through email. Kindly call the office as soon as you finish the paperwork.

Greetings from @Ease Psychiatry!

Kindly complete all the forms below. You are also required to send us a copy of your insurance (front and back) as well as any valid ID through email. Kindly call the office as soon as you finish the paperwork.

Greetings from @Ease Psychiatry!

Kindly complete all the forms below. You are also required to send us a copy of your insurance (front and back) as well as any valid ID through email. Kindly call the office as soon as you finish the paperwork.