Patient Information
Please provide your details exactly as they appear on your ID and insurance card
Patient Name
*
Date of Birth
*
-
Month
-
Day
Year
Today's Date
-
Month
-
Day
Year
Date
Age
Gender
*
Male
Female
Non-binary / Third gender
Prefer not to say
Prefer to self-describe
Address
*
Phone Number
*
Format: (000) 000-0000.
Email
*
OK to text for scheduling & benefits updates?
*
Yes
No
Coverage type
*
Insurance
No insurance / Self-pay
Back
Next
Insurance Payer Details
Insurance company
*
Please Select
BCBS TX
Aetna
Cigna
UnitedHealthcare/Optum
Humana
Scott & White Health Plan
Oscar, FirstCare
Sendero
Superior HealthPlan
Amerigroup
Community First
Traditional Medicare
Other
Member ID
*
Group Number
*
Are you the primary policyholder?
*
Yes
No
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?
*
Yes
No
Secondary 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
Secondary Member ID
*
Secondary Group Number
*
Secondary card — Front
*
Secondary card — Back
*
Back
Next
Minor (Under 18) — Parent/ Legal Guardian Information
Parent/ Legal Guardian full name
*
Parent/Guardian DOB
*
-
Month
-
Day
Year
Relationship to patient
*
Please Select
Mother
Father
Legal guardian
Managing conservator
Other
Parent/Guardian phone (PRIMARY CONTACT)
*
Format: (000) 000-0000.
Parent/Guardian email (PRIMARY CONTACT)
*
OK to text guardian for scheduling & benefit updates?
*
YES
NO
Address same as patient?
*
YES
NO
Parent/Guardian address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Second parent/guardian to share info with?
*
YES
NO
Second parent/guardian name
*
Second guardian relationship
*
Please Select
Mother
Father
Legal guardian
Managing conservator
Other
Second guardian phone
*
Format: (000) 000-0000.
Custody or legal restrictions?
*
YES
NO
Parent/guardian photo ID — Front
*
Parent/guardian photo ID — Back
*
Parent/Guardian signature
*
Date
-
Month
-
Day
Year
Date Picker Icon
Hour Minutes
AM
PM
AM/PM Option
Back
Next
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?
*
Preferred Pharmacy – Name & Address
*
Back
Next
Suicide Risk Assessment
Over the past month, have you wished you were dead or wished you could go to sleep and not wake up?
*
YES
NO
Over the past month, have you had any actual thoughts of killing yourself and have you been thinking about how you might do this?
*
YES
NO
Over the past month, have you started to work out or worked out the details of how to kill yourself?
*
YES
NO
If YES, at any time in the past month did you intend to carry out this plan?
*
YES
NO
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)?
*
YES
NO
If YES, was this within the past 3 months?
*
YES
NO
Emergency Contact Name
*
Emergency Contact Phone Number
*
Format: (000) 000-0000.
Emergency contact Relationship
*
Back
Next
Authorizations, Consents & Signature
Government ID (Front) -Upload a clear photo of a driver’s license, state ID, or passport
*
Government ID (Back) -Upload a clear photo of a driver’s license, state ID, or passport
*
*
Patient/ Guardian Signature
*
Date
-
Month
-
Day
Year
Date Picker Icon
Hour Minutes
AM
PM
AM/PM Option
Back
Next
Almost Done
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
Psychology Today
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
gclid
utm_source
utm_medium
utm_campaign
utm_term
utm_content
traffic_source
Submit
Should be Empty: