Psych Appointment Request Form

Theory Mental Health Intake Form

Questions? Contact us at (866) 703-7033 or by email at info@theory-health.com
Client's Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Date of Injury / Loss*

MonthDayYear
Date
Phone*
Please enter a valid phone number.
Client's Email (optional)
example@example.com
Gender:*

MaleFemale
Language:*
Client's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Need to add another person involved in this case? Please include Full Name, DOB, and Phone number of each additional Client/Patient.
Referring Provider or Attorney Name*
Please include First & Last Name
Company Name*
Medical Practice or Law Firm Name
Contact Name*
Point of Contact for Provider / Attorney Office
Attorney or Provider Phone*
Please enter a valid phone number.
Contact Email*
example@example.com
Case Type*
Policy Limits*
*If unavailable, please type "unavailable". If limits not yet identified, please provide when available
Preferred Pharmacy
*If left blank, our providers will utilize a pharmacy that accepts LOPs/NORIs, and who will mail medications directly to your client's home.
Notes / Instructions
*Please provide any relevant notes or instructions here.
Please include LOP / NORI here (or email to info@theory-health.com )

Please address to: Theory Health, LLC, 18911 Hardy Oak Blvd, #200, San Antonio, Texas 78258
Cancelof
Privacy Statement

Theory Health, LLC values your privacy and assures you we will never give or sell your personal information, that of a client and or patient to any third parties. All personal information you provide (i.e.: name, address, email address and telephone number) will be kept confidential and will only be used to provide services by Theory Health, LLC, and its affiliates. Those who are given access to your personal information will be required to keep the information confidential and not use it for any other purposes other than the services they are performing for Theory Health, LLC as requested in this intake form.
Should be Empty:

Theory Mental Health Intake Form