New Patient Form
Please complete the fields below. Those items with an *asterisk are required. Detailed forms are available in the drop-down menu on the right. Should you have any questions, please do not hesitate to contact our offices at the number and email address above.
Primary Email
*
example@example.com
Patient's Legal Name
*
First Name
Last Name
Is the patient a minor?
*
Please Select
Yes
No
(Please see the Consent to Treat a Minor form in the drop-down menu on the right.)
If so, do you consent to the treatment of a minor?
*
Yes
No
Reason for visit?
*
Please select what services you are interested in: (Check all that apply)
Medication Management
Therapy
Psychological Testing
Patient's Preferred Name
*
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Patient's Social Security Number
*
Pronoun
*
Please provide the pronoun to be addressed by.
Sex
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Phone Number
*
Please provide the primary phone number including the area code to contact the patient. EX: 319-626-3300
May we identify ourselves when calling?
*
Yes
No
Would you like to sign up for reminders?
*
No
Yes, Text Reminders
Yes, Voice Reminders
Marital Status(required)
*
Please Select
Single
Married
Widowed
Divorced
Partnered
Patient is a Minor
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please Please provide the phone number(s) including the area code of whom we should reach out to with urgent information.
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Insurance Information
Primary Insurance
*
Subscriber ID
*
Group Number
*
Please upload a copy of the front of your insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a copy of the back of your insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Insurance Provider Phone Number
*
This can usually be found on the back of the card.
Client's Employer
*
Subscriber Name
*
Relationship to Client
*
Subscriber Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you have secondary insurance?
Yes
No
Secondary Insurance
Subscriber ID (Secondary Insurance)
Group Number (Secondary Insurance)
Please upload a copy of the front of your secondary insurance card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a copy of the back of your secondary insurance card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Provider Phone (Secondary Insurance)
Will the patient be responsible for their own bills if not, who is the guarantor?
Yes. All information is the same. (Please skip to the HIPPA Policies)
No. (Please complete all Guarantor questions.)
Guarantor Name (person responsible for billing)
First Name
Last Name
Guarantor's Social Security Number
*
Guarantor's Relationship to Client
Guarantor Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Guarantor Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Guarantor Primary Phone Number
*
This can usually be found on the back of the card.
Back
Next
HIPPA
Please see and review the HIPPA Notification of Privacy Policies in the drop down menu to the right.
Signature
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