New Patient Inquiry Form

New Patient Inquiry Form

Compassionate Minds Therapy
Full Legal Name of Patient (No Nicknames)*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Patient's Age*
Social Security Number*
Parent/Legal Guardian Name if Patient a Minor

First NameLast Name
Relationship to Patient (if Self, please mark as Self)*
Email (if no email please mark N/A)*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
This is my*
Alternate Phone Number
Please enter a valid phone number.
This is my
How may we contact you?*

CellHomeWorkEmailOther
Where may we leave you a voicemail?*

CellWorkHomePlease do not leave a voicemailOther
Gender*

MaleFemale
Marital Status*

SingleMarriedDivorcedWidowed
Emergency Contact
Emergency Contact Name*
Phone Number*
Please enter a valid phone number.
Relationship to Patient*
Insurance Policy Information

If you do not have insurance, please mark N/A in the required fields.
Primary Insurance Company (If Medicaid, please indicate which plan you have, i.e. NE Total Care, Healthy Blue, etc.)*
Benefits Phone Number (Please add number from back of card)*
Please enter a valid phone number.
Member ID #*
Group ID #
Policy Holder's Name (If Not Self)
Policy Holder's DOB (If Not Self)

MonthDayYear
Date
Please submit a copy of your insurance card (front and back).

Cancelof
*If you do not have insurance coverage, please call Compassionate Minds Therapy @ 402-238-1431
Reason for Seeking Care
Briefly describe the recent concerns leading you to seek an evaluation/treatment.*
Have you ever been seen or treated for the concern(s) described above, if so, by whom?*
Please list any medications you are currently taking or have taken in the past for the above listed concerns. (If none, please mark N/A)*
Primary Care Provider
Name
Practice Location
Referral Source
Who may we thank for your referral (if self referred, please mark self):*
Signature of Patient or Parent/Legal Guardian(if patient a minor):*

Clear
Should be Empty:

Emergency Contact

Insurance Policy Information

*If you do not have insurance coverage, please call Compassionate Minds Therapy @ 402-238-1431

Reason for Seeking Care

Primary Care Provider

Referral Source