Kind Health: New Patient Form

First Name*
Last Name
Phone Number*
Email*
How will you pay for care?
Insurance Carrier*
Member ID #*
Group ID #*
Date of Birth*

MonthDayYear
Let us know a good time to schedule your appointment. If you don't have a preference, skip to the next section. This time is not guaranteed.
The questions below are optional, but will help us match you to the best provider!
Why are you seeking care? (*select up to 3)

AnxietyAttentional difficultiesBehavioral issuesDepressionGriefRelationship issuesSubstance useTraumaOther
What is your history with mental health? (*select all that apply)

Taking psychiatric medication nowTaken psychiatric medication in the pastHospitalized for mental health reasons now or recentlyHospitalized for mental health reasons in the pastKnown neurologic or genetic disorderNone of these apply
Is there anything else you would like the practitioner to know?
How did you hear about us?
Please be specific.
Should be Empty:

The questions below are optional, but will help us match you to the best provider!