330 West 58th Street | Suite 207 | New York, NY 10019 | Tel: 212.944.8444
     
  New Patient Questionnaire  
 

You can save time in our office by filling out your patient questionnaire form from the convenience of your home. Simply download the form below, complete and bring it with you.

New Patient Questionnaire Form

Note: This file is in PDF format. If you do not have Adobe® Reader® on your computer, you can download it for free by clicking here or on the Get Adobe Reader icon.
 
 
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I want to schedule a consultation with Dr.         Washton in the New York Office
I want to schedule a consultation with Dr.         Washton in the New Jersey Office
 
   

 

 

Your Private Consultation with Dr. Washton

You will be seen personally by Dr. Washton for the initial consultation--to evaluate the nature and extent of your alcohol/drug use and related problems—and to formulate an individualized treatment plan. Once you have set up an appointment with Dr. Washton, please download, print out, and fill out the New Patient Questionnaire and bring this form with you to the appointment.


 

   
   
   
 
 
     
   
     
     
   
     
     
   
     
     
   
 
 
 

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