Appointment/Medication/Questions Request

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Appointment Request | Appointment Cancellation/Reschedule | Medication Refill Request | General Question
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Current Date

MonthDayYear
Date
Age
Phone Number
Please enter a valid phone number.
SMS Communication Disclaimer

Welcome to Synapse Behavioral Health!

We value your privacy and are committed to protecting your confidential information. Please read the following disclaimer regarding our use of SMS messages for patient communication:

1. SMS Communication Purpose

We may use SMS messages to communicate with our patients for the following purposes:
Appointment reminders
Treatment plan updates
Important announcements
General information related to your treatment

2. Privacy Assurance

We will not share any of your personal information or the content of SMS messages with third parties without your explicit consent, except as required by law or for treatment coordination purposes, which will always be handled with the utmost discretion and in accordance with applicable legal and ethical standards.

3. Consent

By providing your mobile phone number and engaging in SMS communication with Synapse Behavioral Health, you consent to receive SMS messages from us for the specified purposes mentioned in this disclaimer.

4. Message Security

While we take measures to secure SMS communication, please be aware that SMS messages may not be entirely secure. It's important not to include highly sensitive or confidential information in SMS messages. If you have concerns about the security of your information, please discuss alternative communication methods with our staff.

5. Opt-Out

You have the option to opt-out of SMS communication at any time. To do so, please contact our office to let us know your communication preferences.

6. Contact Information

If you have any questions or concerns about this SMS communication disclaimer or our privacy practices, please don't hesitate to contact us at 856-399-1010.

Thank you for trusting Synapse Behavioral Health with your care. Your privacy and confidentiality are of the utmost importance to us.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

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Reason for contact*
Message
New patient appointment type
Provider
Please choose symptoms the patient is experiencing:

DepressionMood SwingsAnxietyPanic AttacksDifficulty concentrating (ADD)- Please note that there is a $100 ADD testing fee that is not covered by insuranceOther (Please specify below)
Other Symptoms
Do you currently have a Psychiatrist?
Psychiatrist Name
Do you currently see a Therapist?
Therapist Name
Have you seen a Psychiatrist or Therapist in the past?

NoYes (Please specify name below)
Name of the Psychiatrist or Therapist

Do you currently have thoughts of harming self or others?
Please note that we do not provide crisis or emergency services. Please call 911 or go to a crisis center/emergency room
Is the patient currently aggressive or threatening to hurt self or others?
Please note that we do not provide crisis or emergency services. Please call 911 or go to a crisis center/emergency room
Do you currently have Medicaid?
We are not in network with Medicaid - but are welcome to see our providers as a self pay patient. Please see our insurance page for self pay rates
Do you currently have Medicare?
Photo of Medicare Card

Cancelof
Is Medicare your Primary or Secondary?
Do you have additional Insurance?
Do you have Insurance?
Insurance Carrier
*Please note that Tricare & Humana patients need to have an Authorization letter from your insurance. Please request an appointment only if you are able to obtain an authorization letter
Other Insurance Carrier Name
Photo of Front of the Insurance Card

Cancelof
Photo of Back of the Insurance Card

Cancelof
How did you hear about us?
Please state "Other"
Current Appointment Date

MonthDayYear
Reschedule Requested?

Pharmacy Name and Contact Number
Do you currently suffer from depression?
How many medications have you tried and failed for depression?

Do you currently have a Psychiatrist?
Psychiatrist Name
Should be Empty:

	Medication Name	Dose
1
2
3
4
5

	Medication Name	Dose
1
2
3
4
5

	Medication Name	Dose
1
2
3
4
5

Contact Us

Please note that we do not provide crisis or emergency services. Please call 911 or go to a crisis center/emergency room

Please note that we do not provide crisis or emergency services. Please call 911 or go to a crisis center/emergency room

We are not in network with Medicaid - but are welcome to see our providers as a self pay patient. Please see our insurance page for self pay rates

*Please note that Tricare & Humana patients need to have an Authorization letter from your insurance. Please request an appointment only if you are able to obtain an authorization letter