New Patient Inquiry Form
Compassionate Minds Therapy
Full Legal Name of Patient (No Nicknames)
*
First Name
Last Name
Patient's Date of Birth
*
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Year
Patient's Age
*
Social Security Number
*
Parent/Legal Guardian Name if Patient a Minor
First Name
Last 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
City
Please Select
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Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
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Nevada
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New Mexico
New York
North Carolina
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Ohio
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Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
This is my
*
Please Select
Cell Phone
Home Phone
Work Phone
Alternate Phone Number
Please enter a valid phone number.
This is my
Please Select
Cell Phone
Home Phone
Work Phone
How may we contact you?
*
Cell
Home
Work
Email
Other
Where may we leave you a voicemail?
*
Cell
Work
Home
Please do not leave a voicemail
Other
Gender
*
Male
Female
Marital Status
*
Single
Married
Divorced
Widowed
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)
-
Month
-
Day
Year
Date
Please submit a copy of your insurance card (front and back).
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*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):
*
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