Prospective Patient Referral Form

Our providers are Nurse Practitioners and provide medication management with supportive therapy. They DO NOT do therapy alone. If you are looking for diagnosis and potential treatment with medication management, please agree.*

I agree

Our Billing Policy (Please read and acknowledge) We only accept certain commercial insurances at this time. New patients will have to enter their insurance with Headway prior to their first visit. We do provide a medical receipt (superbill) that you may submit to your insurance for possible reimbursement. Reimbursement rates are plan specific and range from 0-100% coverage. You should contact your insurance to inquire about your plans reimbursement rates for "out of network" psychiatry services. Payment is due in full before each visit, all forms of payment accepted.*

I agree

Full Legal Name*

Date of Birth*

Date

Gender at Birth*

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Mobile Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Please provide a brief description of your mental health history and your reason for seeking treatment at this time.*

Have you ever had any suicidal ideation, suicide attempts or self harm? If yes, please describe and give dates. Were you hospitalized for this? *

If no history, simply write NONE.

Have you ever received treatment for substance abuse?*

Yes, currentlyYes, completedNo, never

Medication List or Medication Requests (type none if applicable)*

Name of your Insurance Company and your ID number as it appears on your card.*

If none, write SELF PAY

Is this evaluation associated to any court or legal proceedings?*

YesNo

If yes, please explain.

Preferred Provider*

Appointment Type Preference*

Ideal Timeline for Initial Visit*

How did you find out about us? Please include name if referred. *

By signing, you are agreeing that the information provided is accurate to the best of your knowledge. Thanks *

Click for our website

Thank you for your interest in becoming a new patient. We will contact you within the next 48 hours. In the meantime, visit our website to see frequently asked questions and other important information about our practices.