Mindscape Psychiatry New Patient Form

Mindscape Psychiatry New Patient Form
If you're looking to be enrolled in our clinic as a new patient, please accomplish this form. Please note that the information enrolled here are protected by HIPAA standards of confidentiality and will be stored for clinical use only.

If you have any questions or concerns, please contact us through:
Email: contact@mindscapepsychiatry.com
Phone: (240) 484-4226 (for MD, DC, and VA patients); (972) 360-8242 (for TX patients)
New Patient Policy: Before proceeding, please be informed that our clinic requires a $39 deposit for new patients, which would be reimbursed or deducted from your copayment or out-of-pocket expenses as you continue with your visits at our clinic.*

I understand the New Patient Policy and would like to continue.
Demographic Information
Full Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex at Birth*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState (MD, VA, DC, TX)

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Type of Appointment Needed*

Psychiatric EvaluationPre-Bariatric EvaluationMedical Marijuana Evaluation (for MD residents)Emotional Support Animal (ESA) Evaluation

Other Details
Where did you hear from us?*

Clinic WebsiteReferral by PCPPsychology TodayAdvertisementFamily/FriendSearch engine (Google, Bing, Yahoo, etc.)Other
Do you have anything that we should take note of? (Current diagnoses, medications, other concerns)
Final Reminders

After entering your details here, we will verify your insurance coverage and contact you to book your appointment. Please submit your form now. Thank you.
Should be Empty:

Demographic Information