Patient Information
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Gender
*
Male
Female
Non-binary / Third gender
Prefer not to say
Prefer to self-describe
Age
Today's Date
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
OK to text for scheduling & benefits updates?
*
Government ID (Front) -Upload a clear photo of a driver’s license, state ID, or passport
*
Government ID (Back)- Upload the back of the same ID
*
Emergency contact name
Relationship to you
Please Select
Spouse
Parent
Domestic Partner
Other
Emergency contact number
Please enter a valid phone number.
Preferred Pharmacy – Name & Address
*
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Minor (Under 18) — Parent/Guardian Information
Are you the patient’s parent or legal guardian?
*
Parent/Guardian full name
*
First Name
Last Name
Parent/Guardian date of birth
-
Month
-
Day
Year
Date
Relationship to patient
*
Please Select
Mother
Father
Legal guardian
Managing conservator
Other
Address same as patient? (Yes/No)
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Parent/Guardian email
example@example.com
Second parent/guardian to share information with?
*
Second parent/guardian name
*
First Name
Last Name
Relationship to patient
*
Please Select
Mother
Father
Legal guardian
Managing conservator
Other
Second parent/guardian phone Number
*
Please enter a valid phone number.
Custody or legal restrictions? (Yes/No)
*
Upload parent/guardian photo ID — Front
*
Upload parent/guardian photo ID — Back
*
Parent/guardian signature
*
Date
*
-
Month
-
Day
Year
Date Picker Icon
Hour Minutes
AM
PM
AM/PM Option
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Insurance Payer Details
Coverage type
*
Commercial/Employer plan
Marketplace/Exchange (ACA)
Medicare
Medicaid (State)
TRICARE
VA Community Care
No insurance / Self-pay
Other
Are you the primary policyholder?
*
Insurance company
*
Please Select
BCBS TX
Aetna
Cigna
UnitedHealthcare/Optum
Humana
Scott & White Health Plan
Oscar, FirstCare
Sendero
Superior HealthPlan (TX Medicaid)
Amerigroup
Community First
Traditional Medicare
Other
Member ID
*
Group Number
*
Policyholder name
*
First Name
Last Name
Policyholder date of birth
*
-
Month
-
Day
Year
Date
Relationship to Patient
*
Please Select
Self
Spouse
Parent
Domestic Partner
Other
Insurance card — Front
*
Insurance card — Back
*
Do you have a secondary insurance?
*
Insurance Company
Please Select
BCBS TX
Aetna
Cigna
UnitedHealthcare/Optum
Humana
Scott & White Health Plan
Oscar, FirstCare
Sendero
Superior HealthPlan (TX Medicaid)
Amerigroup
Community First
Traditional Medicare
Other
Member ID
Group Number
Insurance card — Front
Insurance card — Back
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Visit Type & Reason for Visit
Visit Type Preference
*
In-person visit at our Austin clinic (Georgetown coming soon)
Telehealth (video) visit – I prefer to be seen by video
I’m comfortable with either in-person or telehealth – I’m flexible
Primary reason for appointment
*
Please describe current symptoms or concerns
*
Current medications?
*
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Suicide Risk Assessment
Over the past month, have you wished you were dead or wished you could go to sleep and not wake up?
*
Over the past month, have you had any actual thoughts of killing yourself and have you been thinking about how you might do this?
*
Over the past month, have you started to work out or worked out the details of how to kill yourself?
*
If YES, at any time in the past month did you intend to carry out this plan?
In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life (for example, collected pills, obtained a gun, gave away valuables, went to the roof but didn't jump)?
*
If YES, was this within the past 3 months?
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Authorizations, Consents, and Clinic Policies
Signature
*
Date
-
Month
-
Day
Year
Date Picker Icon
Hour Minutes
AM
PM
AM/PM Option
How did you hear about us?
*
Referred by a Doctor/ Facility
Referred by a friend or family member
Insurance provider
Online search (Google, Bing, etc.)
Social media (Facebook, Instagram, etc.)
Advertisement (print, online, or other)
Walk-in / Saw your clinic
Other
Referred Doctor/ Facility Name, Address and Phone number
If a doctor or clinic referred you, please share their name and contact details so we can coordinate your care
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