New Patient Appointment Request Form

New Patient Appointment Request Form
Patient's Full Legal Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
Date
Phone Number
May we use sms/text messaging to communicate with you?
Email
example@example.com
May we use email to communicate with you?
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Full Name of Person Completing Appointment Request Form
Relationship to Patient
Insurance
If you do not have insurance or do not wish to use insurance please put "Private Pay"
Insurance Card

Uploading an insurance card will allow us to verify your coverage and benefits for mental health services.
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Reason for Appointment - Please tell us why you're seeking a psychological evaluation/psychological testing.
IMPORTANT PLEASE READ

Please note that we provide evaluation and testing services only. We DO NOT offer therapy/counseling services at this time.

If you are seeking an evluation for a court order, custody or divorce please note that we do not currently provide these services.
NEXT STEPS

Once you submit your appointment request, you will receive an email from therapyportal.com with a link to create your secure patient portal and complete the registration. Please allow 24 hours or next business day if submitted Friday-Sunday. Please be sure to check your junk/spam folder for this email before reaching out for assistance.

Please get in touch with our scheduling team by emailing scheduling@psychologyok.com, and we'll be happy to assist you if you don't receive the email.

Please note, we do require complete registration prior to scheduling to ensure you are scheduled with the provider that best fits your needs.
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