New Patient Request Form

New Patient Request Form
Thank you for your interest in becoming a patient at Joyful Mind Psychiatry. To ensure we can provide the best care for you or your child, please fill out the form below. If you are a parent or guardian completing this form, please include your details in the appropriate sections. If any additional information is needed, we will reach out to you.

If the patient is an independent adult age 18 or older, we cannot accept appointment requests from parents. The patient must work directly with us to request services, complete the required paperwork, and schedule their appointments. We do offer text messaging and email for communication to complete this process.
Patient Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Patient Age*
Gender*
Preferred Pronouns
Parent/Guardian Name
Skip if you are an adult requesting services for yourself.
Relationship to Patient
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number*
Email*
Primary Insurance Carrier*
Where would you like to receive services?*
How did you hear about Joyful Mind Psychiatry?*
What services are you seeking? (select all that apply)*

Psychiatric Diagnostic EvaluationMedication ManagementPediatric Autism Evaluation (Age 10+)Pediatric ADHD Evaluation (Age 10+)Adult Autism Evaluation (Age 18+)Adult ADHD Evaluation (Age 18+)Individual Therapy **FULL - WAITLIST AVAILABLE**

If you indicated you are seeking an ADHD or Autism evaluation, please read below, otherwise, please skip to the next section.

Our Autism and ADHD evaluations are not appropriate for individuals with a suspected learning disability, who are non-verbal, or require significant support. This evaluation is best suited for individuals who:
- Want some clarity and direction about their symptoms and experiences.
- Are seeking possible medication management for their symptoms.
- Understand that a diagnosis of ADHD or Autism may not be the outcome of this assessment.
To arrive at an accurate diagnosis, 2-3 appointments may be necessary in order to collect sufficient information for diagnosis.

Statement of Medical Necessity: Your insurance may not cover the evaluation or additional appointments if your symptoms are not causing significant dysfunction or disruption to your quality of life and ability to function on a daily basis. It is the patient's responsibility to check with their insurance carrier regarding coverage.
If you indicated above that you are seeking and ADHD or Autism evaluation, please respond to the following:

By checking this box, I acknowledge that I have read and understand the above information regarding eligibility for ADHD and/or Autism evaluations.