Request appointment | Alicia Kimball, APRN, PMHNP-BC

Alicia Kimball, APRN, PMHNP-BC

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Reason for care

Select date & time

1 Appointment info

2 Prescreener

Reason for care

3 Contact information

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

What kind of care is being sought?

Psychotherapy Medication Other Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Is this appointment related to a recent psychiatric hospitalization or emergency room visit?

Yes or No

Are you currently taking any psychiatric medications?

This includes stimulants, antidepressants, benzodiazepines, sleep medication, anxiolytics, antimanics, antipsychotics, etc.

Are you currently engaged in therapy?

Yes or No (if yes, please provide name of therapist)

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

Alicia Kimball

207.690.5697 |

Laconia

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THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.