top of page

Megan Resnick Nurse Practitioner
Board Certified in Psychiatry

Home
New Patient
General
Refills
Appt. Changes
Resource Link
More

Use tab to navigate through the menu items.

Phone: (203) 290-1732
Fax: (833) 605-4110

Email: adminsupport@claritymbwellness.com

Hours:
Sat- Monday: Closed
Tuesday-Friday: 9:30 am- 4:00pm

Hey There

Date and time

Month

Day

Year

Time

First name

Last name

Phone

Birthday

Month

Day

Year

Country/Region

Address

City

Zip / Postal code

Referred by:

Mental Health History:(Required)

Please provide detailed mental health history, including any history of psychiatric hospitalizations.

Substance Abuse history:(Required)

Are you currently or do you have a history of substance abuse?

Current Psychiatric Medications:(Required)

Please list all psychiatric medications you are currently prescribed.

Who is prescribing your psychiatric medications now?(Required)

Ex: Primary care doctor, OBGYN, previous psychiatrist.

Are you in a crisis? (Emergency)(Required)

Yes

Symptoms: Please select all that apply to your reason for seeking care.(Required)

Depression

Anxiety

OCD

Panic

Stress

Anger

Grief

Trauma

Sleep issues

Mood swings

Obsessive thoughts

Alcohol abuse

Substance abuse

Legal

Self Harm/ Self Injury

Academic issues

Eating disorder

Self Esteem

Procrastination

Cognitive changes

Sexuality

Identity issues

Difficulty functioning

Compulsive behaviors

Other

Please provide some information on why you are seeking care?(Required)

What is your goal for treatment?(Required)

Insurance name:(Required)

Insurance Member ID:(Required)

Insurance Group#:

Photo: Front of Insurance card(Required)

Photo: Back of Insurance Card(Required)

NYS Photo ID(Required)

bottom of page

Megan Resnick Nurse Practitioner Board Certified in Psychiatry

Hey There

Megan Resnick Nurse Practitioner
Board Certified in Psychiatry