New Patient Registration Form

New Patient Registration Form

Prospective patients: please complete and submit this form. We will be in touch as soon as possible.
Demographic & Medical Information
Legal Name*

First NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
Legal Sex*

MaleFemale
Pronoun (optional)

he/himshe/herthey/them
Relationship status*
Sexual identity (optional)
Email*
Primary Phone*
Please enter a valid phone number.
Best Way to Contact You to Schedule Your First Appointment (we generally respond within 24 to 48 hours after form submission)*

Phone CallEmail
Current residential address (do not use P.O. Box)*

Street Address

Stress Address 2

CityState / Province

Postal / Zip Code
Emergency contact*

First NameLast Name
Phone Number*
Emergency contact relationship to patient*
What brings you to make this appointment? (Please note, we're not offering therapy-only visits at this time.)*
for example: medication management, depression, anxiety, bipolar disorder, PTSD etc.
Have you been diagnosed with any of the following psychiatric conditions by a professional?*

NONEDepressionAnxiety disorder(s)Panic disorderOCDBipolar disorderPTSDEating disordersPersonality disorderSchizophreniaInsomniaOther
Medical Conditions (include all from past and present)*
Ex. high blood pressure, heart attack, arrhythmias, seizure, asthma, diabetes, thyroid disease, IBS, cancer, high cholesterol, stroke, arthritis, lupus, hepatitis, HIV, sleep apnea or write NONE)
List all CURRENT medications (name, dose, how often you take the medication)*
List any past psychiatric medications to the best of your knowledge*
Have you been hospitalized in an inpatient psychiatric hospital in the past?*
Do you currently or previously smoke cigarettes or use nicotine?*
Alcohol consumption level*
Cannabis/marijuana use*
Do you have an active or history of addiction/substance use disorder (Illicit or prescribed)?*

Yes - current useYes - past useNo
Select substance(s) used:

AlcoholCocaineMethamphetamineStimulants (eg, Adderall, Ritalin)Opiates (eg, heroin, oxycodone)Benzodiazepines (eg, Xanax, Klonopin)Hallucinogens (eg, ketamine, LSD, mushroom, MDMA)Other
Driver's license*

A legal, unexpired, picture ID (e.g. passport or driver's license)
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Billing & Payment Information
Will you being using health insurance OR self-pay? (We cannot accept clients with any Medicare, 'Ohana Health, or Kaiser plans)*

InsuranceSelf pay
Primary insurance

(!! IMPORTANT!! If you are covered by more than one insurance (including out of state insurance), please provide that information. Failure to provide that information could result in claim denial and balance will be paid out of pocket by responsible party.)
Primary insurance policyholder name*

First NameLast Name
Insurance company
Insurance ID #
Upload insurance card (Front)*

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Upload insurance card (Back)*

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Do you have another insurance?*

YesNo
Secondary insurance primary policyholder name*

First NameLast Name
Insurance company
Insurance ID #
Upload secondary insurance card (Front)*

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Upload secondary insurance card (Back)*

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PLEASE NOTE:

- Controlled substances prescriptions must be paid using insurance at the pharmacy. Please contact your insurance company for an in-network pharmacy in Hawaii.

- We charge fees at the beginning of the appointment and require a credit card authorization on file for individuals opting to self pay and with deductibles.
How did you hear about us?*

Google searchPsychology TodayFacebookTwitterInstagramOther
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New Patient Registration Form

Demographic & Medical Information

Billing & Payment Information

Primary insurance