THE BRIARWOOD CLINIC
Incomplete or unsigned registration packets will not be accepted. Please check for accuracy before submitting. DO NOT SUBMIT IF YOU HAVE NOT CALLED TO SCHEDULE AN APPOINTMENT!!
Today'sDate
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you hear about us?
Yellow Pages
Internet Search
Friend/Family
Professional
Insurance
Other
Marital Status
Please Select
Married
Single
Widowed
Divorced
Employment Status
Please Select
Employed FT
Employed PT
Student
Employed and Student
Retired/Unemployed
Patient Name
*
First Name
Middle Initial
Last Name
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Number
AT LEAST ONE CONTACT PHONE IS REQUIRED
Format: (000) 000-0000.
Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alt Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Social Security Number
111-11-1111
Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Biological Sex:
*
Male
Female
Both
Undetermined
How do you Identify:
Male
Female
Transgender
Other
Send Text Reminders to:
*
Cell phone
Email
OPT OUT of Reminders
Other
If patient is a minor, please complete the Responsible Party Section below.
If you are NOT the parent or legal guardian of a minor, you cannot consent to treatment. Legal guardianship requires documentation of proof before minor patient can be seen. All responsible parties listed MUST sign financial agreement and consent.
RESPONSIBLE PARTY 1
RP 1 ADDRESS
RELATION TO MINOR
Choose one:
PARENT
Legal Guardian
POA
SIGNATURE (Required if patient is a minor)
RESPONSIBLE PARTY 2
ADDRESS
If different than Responsible Party 1
RELATION TO CHILD
Choose One:
PARENT
Legal Guardian
POA
SIGNATURE
If you have insurance you wish to be billed, please complete the section below. If you do not have insurance please see the financial agreement for Selfpay Rate.
An uploaded picture of ALL insurance cards (front and back) is required.
Primary Insurance (If none, enter "NONE")
*
Member ID: (If no insurance, enter "N/A")
*
Policy Holder Name:
First Name
Last Name
Relationship to Patient:
Group #
Policy Holder's DOB:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Policy Holder's Address if different from patient:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Holder's Employer:
Deductible:
Copay/Coinsurance
REQUIRED!!! Take a CLEAR and Up Close Picture of: 1. Front AND Back of ALL Insurance Cards AND, 2. Front of Driver's License or Picture ID of Patient (or Responsible Party(s))
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Secondary Insurance Co:
Required if you have a secondary insurance
Secondary Ins Member ID:
Secondary Policy Holder:
First Name
Last Name
Relationship to patient:
Group #
Secondary Ins Policy Holder D.O.B.
Address if different than patient
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Policy Holder's Employer
Deductible:
Copay:
Financial Agreement
Please read and review entirely before signing. Your signature indicates you understand and agree to adhere to the financial agreement. This must be completed and signed before a patient can be seen.
Patient Name:
*
First Name
Last Name
Signature of Patient (or Responsible Party 1)
*
**Minors CAN NOT sign
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Rights and Responsibilities
Please read and sign.
Patient Signature/or Responsible Party 1
*
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of 2nd Patient/or Responsible Party 2
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PATIENT HISTORY
Please complete to the best of your ability, sign and date.
Patient Name:
*
First Name
Last Name
Patient DOB:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is your primary sexual orientation?
Heterosexual
Gay
Lesbian
Bisexual
Asexual
Pansexual
Prefer Not to Say
Other
What is your Race/Ethnicity:
White
Black/African American
Asian
Hispanic
Pacific Islander
Prefer Not to Say
Other
What led you to seek counseling?
Self
Friends/Family
Employer
Doctor
Please describe your current symptoms or concerns.
Suicidal Thoughts/Attempts? If yes, how recently and do you currently feel at risk?
Is there a history of previous counseling?
No
Yes
Where:
When?
Counselor:
Was a psychiatric diagnosis made?
No
Yes
If Yes, What?
Are you currently under a doctor's care?
No
Yes
Other
List current medications you are taking:
Are you currently using or abusing any chemical substances?
NO
YES
Chemical and Frequency of use
Is there a past history of substance abuse?
NO
YES
Length of Sobriety:
Are there any Medical Conditions this office should be informed of?
NO
YES
If Yes, What:
Names and Ages of Immediate Family (in your household):
Emergency Contact:
*
First Name
Last Name
Emergency Contact Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2:
*
First Name
Last Name
Emergency Contact 2 Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature of Person Completing Form:
*
Signer's Relationship to Patient:
*
Ex: Self , Mother, Guardian
COORDINATION OF CARE
Please complete this form to consent or decline coordination of care between your mental health provider and your primary care physician (PCP). If you do not have a PCP, complete and sign the form but enter NONE in the PCP field.
Communication between Behavioral Health Providers and your Primary Care Physician is important to ensure that you receive comprehensive and quality health care. This form will allow your Behavioral Health Provider to notify and share Protected Health Information (PHI) with your Medical Doctor. This information will not be provided without your signed consent. PHI may include diagnosis, treatment plan, progress, and medication if necessary (and provided).
Patient Full Name:
*
First Name
Middle Initial
Last Name
Patient DOB:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Care Physician Name:
*
First Name
Last Name
PCP Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
PCP Fax:
Please enter a valid phone number.
Format: (000) 000-0000.
PCP Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Consent to Coordinate Care with your PCP: (You must choose one)
*
I give consent
I DECLINE CONSENT
Signature of Patient (Or parent/guardian)
*
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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