New Patient Intake Form for NJ, NY, MA, NH, and FL residents only.
Complete the following form in order for your insurance information to be verified for coverage of our services. We will reach out to you at the email you provide to inform you whether or not our services are covered by your plan within 24-48 hours. Please check your spam for an email from info@empathwell.com. Also, note that we are currently only servicing patients in NJ, NY, MA, NH, and FL.
We are not currently enrolled with Medicare or Medicaid. Is your primary insurance Medicare or Medicaid?
*
Yes
No
We apologize but we are not currently enrolled with Medicare or Medicaid. Please utilize your insurance website to find a provider within your network. If you would like to engage in care as a self-pay patient, you may contact us at info@empathwell.com
Patients Name
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First Name
Last Name
Patient's Age
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Sex (Please note that most insurances require this for verification purposes and do not allow for alternative options)
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Male
Female
Phone Number
*
Please enter a valid phone number.
Email Address
*
Patient's Date of Birth
*
Height
*
Please Select
4'1"
4'2"
4'3"
4'4"
4'5"
4'6"
4'7"
4'8"
4'9"
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'0"
7'1"
7'2"
7'3"
7'4"
7'5"
Weight (lbs)
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Brief explanation of request for psychiatric consultation
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0/30
Are you currently working with a therapist?
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Yes
No
Therapist's Name
*
Therapist's Phone Number
Please enter a valid phone number.
Therapist's Email Address
Do you give consent to Empath Psychiatry to discuss the full details of your case and care with your therapist?
*
Yes
No
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you had any adverse reactions to any psychiatric medications?
*
What medications are you on currently? Please provide Name, Dosage, Frequency, and Time of Day (If none, type n/a)
*
Pharmacy Information (If you don't have a pharmacy, choose a pharmacy nearest to you)
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Pharmacy Name
Street Address
City
State / Province
Postal / Zip Code
Are you currently Employed?
*
Yes
No
Hours Per Week
*
Please Select
Full-time
Part-time
Per-diem
n/a
Job Title
Do you have insurance?
*
Yes
No
Insurance Carrier
*
Member ID Number
*
Group ID
*
Address Asssociated with Insurance
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you the main policy holder?
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Yes
No
Main Policy Holder's Name
*
First Name
Last Name
Main Policy Holder's Relation to Patient
*
Please Select
Mother
Father
Husband
Wife
Spouse
Caregiver
Other
Main Policy Holder's Date of Birth
*
/
Month
/
Day
Year
Date
Patient picture ID
*
Insurance Card Front
Insurance Card Back
If you can not take a picture of your insurance card, you may upload here:
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Empath Psychiatry provides 100% remote care utilizing our mobile app which can be found in your respective app store on your smartphone. Please provide your smartphone type so that the proper store link may be sent to you. The app is free and has many capabilities that will insure that your care is a seamless as possible.
If you do not have a smartphone and would prefer to engage in care through a lap or desktop computer, please indicate so.
Smart Phone Type
*
Apple
Android
I only want to use my computer for sessions
Other
How did you find us?
*
Please Select
empathwell.com
ALMA
Headway
I am a previous patient
None of these
Through another patient
My Therapist
Psychology Today
Google
Please elaborate
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Emergency Contact Relationship
*
Please Select
Mother
Father
Brother
Sister
Husband
Wife
Partner
Girlfriend
Boyfriend
Friend
Other
Submit
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