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
2 digit month, 2 digit day, 4 digit yearDate
Date of Injury / Loss

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Client's Email (optional)
example@example.com
Gender:
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.Format: (000) 000-0000.
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
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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.
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Theory Mental Health Intake Form