Request an appointment

Welcome to Vita Health!
If you're ready to start care, please fill out form below. It's just like those standard forms you complete in-person at an office. If you're not ready to schedule but want to learn more, email us at support@vitahealth.care

We will use this information to get you started and to check on your insurance benefits. Please note that you should always check with your insurance carrier directly about your mental health benefits.

After you complete this form, a Vita care coordinator will review and reach out about scheduling your first appointment! You can always call us when you complete the form for faster scheduling. Our team can be reached at (844) 866-8336.
Submission Datetime

YearMonthDay
Hour MinutesAM/PM Option
Vita Email
example@example.com
YesNo
If you are a provider referring a patient, please use this patient referral form.

If you are a parent or guardian filling this form out on behalf of a minor patient, please continue.

If you are filling out this form on behalf of an adult patient, please ensure that the patient signs in the Patient Signature field.
Patient date of birth*

MonthDayYear
YesNo
The patient's legal guardian will receive appointment reminders and other information on behalf of a minor patient, unless otherwise specified.
Current Date

MonthDayYear
Date
Patient age
Legal guardian name*

First NameLast Name
Legal guardian date of birth*

MonthDayYear
Legal guardian phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Legal guardian email*
example@example.com
Name of person completing form*

First NameLast Name
Phone number of person completing form*
Please enter a valid phone number.Format: (000) 000-0000.
Phone number extension
Email of person completing form*
example@example.com
What is your relationship to the patient?*
Patient information
Patient legal name*

First NameMiddle NameLast Name
Patient preferred name
Sex assigned at birth*
Patient phone number*
Format: (000) 000-0000.
Patient email*
Patient address*

Street Address

Street Address Line 2

CityState

Zip Code
Preferred language
Referring provider/entity name*
E.g. provider office name, insurance name, etc. If you are seeking care without a referring provider, please type "self".
Primary care provider name
E.g. provider office name, insurance name, etc
Primary insurance*
Primary insurance member ID*
YesNo
Primary insurance subscriber name
If you or the patient are not the subscriber on the account, please provide the name of the subscriber. This allows us to easily verify your benefits.
Primary insurance subscriber date of birth

MonthDayYear
Date
Primary insurance card - image of front

Cancelof
Primary insurance card - image of back

Cancelof
Talk TherapyMedication ManagementCare for suicidal thoughts or self-harm behaviorsCare for those who have a loved one with suicidal thoughts or self-harm behaviorsYouth Nominated Support Program
Additional details about reason for visit
How did you hear about Vita Health?
How should we get in touch with you?*
- Consent for Services
- By signing below, I acknowledge that I have read Vita Health's Consent For Services and Controlled Substances policy. I also acknowledge that if I had any questions, they were answered to my satisfaction. I was made aware that I can revoke this consent at any time by submitting a request in writing to support@vitahealth.care.
- Patient signature
  
  Clear
- Parent / legal guardian signature
  
  Clear
- Should be Empty:

Welcome to Vita Health!

Patient information

Consent for Services