Privacy & Technology Notice

Your care stays entirely human, private, and directly managed by Dr. Krasnova.

I do not use artificial intelligence (AI) tools, AI transcription, AI note-generation, or any third-party AI services during sessions or in my clinical documentation.

All information discussed in appointments is kept strictly confidential and handled only through secure, HIPAA-compliant systems under my direct control. Your personal information is never shared with external AI databases or used for automated analysis of any kind.

My practice values privacy, discretion, and the integrity of the therapeutic relationship. Every aspect of your care is handled by me — not by automated systems.

Form 1 of 7

New Patient Intake Form

* Indicates required field

Patient Information

Today's Date *

First Name *

M.I.

Last Name *

Date of Birth *

Social Security Number *

Marital Status

Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Contact Information

Email Address *

Home Phone Number

Ok to leave messages?

Work Phone Number

Ok to leave messages?

Mobile Phone Number *

Ok to leave messages?

Employment Information

Occupation

Employer (name of school if student)

Hours Worked Per Week

Prescription Coverage?

Referral & Appointment Information

How did you hear about my services?

What is your reason for making an appointment?

Emergency Contact

Emergency Contact Name

Relationship to Patient

Emergency Contact Address

Emergency Contact Phone Number

Patient Signature

Patient Signature *

Please sign using your mouse or touch screen