Carolina Anxiety Care
New Patient/Wait List Registration Form
Patient Information
Patient Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Age
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Mobile Phone Number
*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Gender
Male
Female
Marital Status
Single
Married
Separated
Divorced
Widowed
Occupation
What is your preferred appointment type?
In Person (Mondays only in Waxhaw)
Virtual (Telehealth T - Th)
Either is ok
Emergency Contact-Name
*
Emergency Contact -Telephone Number
*
Emergency Contact --Relationship to You
*
Medical/Psychiatric Information
Name of Primary Care Physician
Address and Telephone Number of Primary Care Physician
May we contact your PCP to inform him/her of your treatment at Carolina Anxiety Care?
Yes
No
Have you participated in any psychotherapy before?
Yes
No
Are you currently in treatment with a psychiatrist or psychiatric NP?
Yes
No
If yes to above, name, address, and phone number of psychiatrist or psychiatric NP
Please, list your current psychiatric medications
Have you ever been hospitalized for any psychiatric illness?
Yes
No
Locations and Dates of psychiatric hospitalizations, if any.
Current Problem and Symptoms
Please, describe your main reason for coming for therapy?
*
Do you experience any of the following anxiety symptoms?...
Are any of these a problem?...
About how many alcoholic drinks do you have each week?
none
1-3
4-6
more than 7
Health Insurance Information
Primary Health Insurance Company
Insured's Name
Insured's Relationship to the Patient
Insured's Date of Birth
-
Month
-
Day
Year
Date
Insurance ID Number
Insurance Group Number
Insured's Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Health Insurance Company
Secondary Insured's Name
Secondary Insured's Date of Birth
-
Month
-
Day
Year
Date
Secondary Health Insurance ID No.
Secondary Health Insurance Group No.
Secondary Insured's Home Address (if different from any above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Front of Insurance Card
Back of Insurance Card
Signature
*
Submit
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