New Patient Intake and Appointment Request Form

New Patient Intake and Appointment Request Form

Providing exceptional mental health services from licensed and experienced providers.
Questions with the star " * " symbol next to it are required to be filled out.

Questions without the star symbol are recommended, but not required.
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Please select the gender identity listed on your health insurance. *
If completing this form for a child/adolescent, (patient age less than 18) please include the following information regarding the responsible party/parent/guardian of individual.

Name, Responsible Party Date of Birth, Address-Including Zip Code, Phone Number, Email.

Please disregard this section if you are not completing this form for a child/adolescent. Please continue to the insurance upload question. Thank you.
Responsible Party Name
Responsible Party Date of Birth
Address (including Zip Code)
Phone Number
Email (if applicable)
Insurance Details

Insurance NameMember/Subscriber ID
Please upload images of the front and back of your health insurance card. If you would like to utilize self-pay options, please leave this section blank.

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What Services Are you Interested in?*

Psychiatric EvaluationTherapy Services (EMDR, DBT, CBT, and more)Neurological ServicesMaternal Mental Health ServicesTranscranial Magnetic Simulation (TMS)Spravato TreatmentOther
If Other, Please Explain
Which office would you like to be scheduled at?

South County -5000 Cedar Plaza Parkway, St. Louis, MO 63128 (Suite 350)West County -11709 Old Ballas Road, Creve Coeur, MO 63141 (Suite 104)St. Peter's -4905 Mexico Road, St. Peter's, MO 63376 (Suite 300)Columbia, MO -1705 East Broadway, Columbia, MO 65201 (Suite 200)

What Times and Days of the Week Work Best for Scheduling Appointments? Our team will work to schedule you as closely to the selected times and as soon as possible.

	8AM-10AM	10AM-12PM	12PM-2PM	2PM-4PM	4PM-6PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Pharmacy Details:

Pharmacy Name

Street Address

Phone Number State / Province

Postal / Zip Code
Do You currently have a Primary Care Doctor? If so, please list below.
Do You have A Current or Previous Mental Health Diagnosis?
Please list the medications you are currently taking, so our team can effectively place you with one of our providers. If no current medications, please type N/A. *
We utilize this information to ensure you are placed with the provider who can best suit you.
Please provide consent to contact you via text (SMS). By clicking this box you agree to the following:

I hereby consent and state my preference to have my physician, and other staff at Serenity Health LLC communicate with me by email or standard SMS messaging regarding various aspects of my medical care. I understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS messaging regarding my medical care might be intercepted and read by a third party.
SMS Consent Confirmation*

Yes, I consent to SMS messagingNo, I do not consent to SMS messaging.
If you do not consent to SMS messaging, our team will reach out to you via phone to schedule an appointment. Or, you can call our team at (314)590-3721 to schedule an appointment.

We look forward to helping you through your mental health journey.
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