New Patient Registration Form

New Patient Registration Form

Welcome! To book a session, please complete and submit this form. We will be in touch within 24-48 hours!
Demographic & Medical Information
Legal Name

First NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
Legal Sex
Pronoun (optional)
Relationship status
Sexual identity (optional)
Email
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Best Way to Contact You to Schedule Your First Appointment (we generally respond within 24 to 48 hours after form submission)
Current residential address (do not use P.O. Box)

Street Address

Stress Address 2

CityState / Province

Postal / Zip Code
Emergency contact

First NameLast Name
Emergency Contact Phone
Format: (000) 000-0000.
Emergency contact relationship to patient
What brings you to make this appointment?
Unfortunately, we do not offer standalone psychotherapy session at this time.
We do not perform psychological evaluations or assessments for any third party or clearance purposes, including employment, firearms, disability, court, other medical or cosmetic treatments, or substance use treatment admissions.
Please describe your reasons for making this appointment (optional)
Have you been diagnosed with any of the following psychiatric conditions by a professional?

Other
Medical Conditions (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)?
Select substance(s) used:
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)
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?
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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Self-Pay Rates:

A credit or debit card is required on file and payment will be processed at the start of each appointment.

$250 plus 4.712% tax for 60-minute appointments

$125 plus 4.712% tax for 30-minute appointments.
How did you hear about us?

Other
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New Patient Registration Form

Demographic & Medical Information

Billing & Payment Information

Primary insurance