Patient Qualification Form
Your information is confidential, HIPAA-compliant, and reviewed only by our medical team for your care. It’s not shared with anyone else without your consent, per state and federal laws.
Client Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Please Enter your City and Zip Code below
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a health insurance?
*
Yes
No
Do you have any of the insurance listed below? If you are not sure we can help you find out.
*
Please Select
Original Medicare (Parts A & B)
Original Medicare with Medicare Supplement
Medicare Advantage PPO Plan (Part C)
Medicare Advantage HMO Plan (Part C)
Not Sure
Other
Do you pay extra premium for this plan?
*
Yes
No
Do you generally need a referral to see a specialis
*
Yes
No
Which conditions has been affecting you most?
*
Check
Short Notes
ADHD
Anxiety
Attention disorders
Autism
Chronic Pain
Depression
Eating Disorders
Emotional and behavioral disorders
Insomnia (Sleep problems)
Memory Disorders
Migraines
OCD
Panic attacks
PTSD
Seizures
Stress
Traumatic brain injury
Other
Share What’s on Your Mind
We’re here for you every step of the way. Please share anything you’d like us to know—your concerns, experiences, or goals. Your input helps us tailor our care to support you best.
Date
-
Month
-
Day
Year
Date Picker Icon
Signature
Submit
Should be Empty: