New Patient Intake Information Form
If you would like to become a new patient of Hagan Health, please fill out the form below.
Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth:
*
-
Month
-
Day
Year
Date
Sex:
Male
Female
Phone Number:
*
Which insurance company do you have?
*
Please Select
Anthem
Humana
Tricare
Medicare
Self- Pay
* We do not accept any Medicaid policies. If you have United Healthcare, UMR, Aetna, or Cigna, we could see you for a self-pay rate*
How did you hear about our office?
Are you looking for counseling, medication management, or both?
*
Please Select
Counseling
Medication Management
Both
What would you like to be seen for?
*
ADHD
Anxiety
Depression
Bipolar Disorder
Eating Disorder
Sleep Disorder
Post Traumatic Stress Disorder
Relationship problems
Stress management
Other
If " Other ", please specify:
Are you currently taking ANY prescription medication? Please specify
*
Are you calling because you're interested in TMS therapy for depression?
Yes
No
I'd like to learn more
Are there any current substance abuse issues?
Yes
No
Do you use any recreational drugs, such as marijuana?
Yes
No
Yes, I'd be willing to stop
Yes, but I'm not willing to stop
Are you currently taking any anxiety medication such as Xanax, Klonopin, Ativan, Valium? If yes, which?
Are you currently in pain management? If so, what is your treatment/medication?
*
Insurance Information:
*
Policy Holder: Policy Holder DOB: Member ID: Group number: Address, if different than the patient:
Submit
Should be Empty: