New Patient Registration
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
Service Type Requested
Please Select
Annual Physical
Medication Management
Medication Assisted Treatment
Psychiatric Evaluation
Individual Therapy
Payment Type/Insurance Provider
Please Select
Medicaid
Blue Cross Blue Shield
Maryland Physician Care
Priority Partners
Aetna
Humana
Insurance/Policy Number
*
(If Self-Pay - Type Self Pay)
Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
ID Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Have you ever seen a mental health doctor in past 30 days?
Yes
No
Have you had previous psychiatric hosptializations?
Yes
No
List of Current Medication
History of Substance use
Yes
No
Who referred you to us? Self/Referring Agency
Please Select
Self
Dr's Office
Local Hospital
Other
Submit
Should be Empty: