New Patient Demographics Form 1

Convenient, Comprehensive Mental Healthcare Tailored to Your Lifestyle.
New Patient Information Forms

Please complete all forms. Upon submission, a staff member will contact you within 48 business hours. If you are experiencing a psychiatric emergency, call 911 or go to your nearest emergency room.
Service(s) that patient is seeking: (Check all that apply)

Psychiatric Evaluation/Medication ManagementPsychotherapy/Counseling (4-6 month waitlist)Psychological/Neuropsych Testing (NJ location only)Executive Functioning Coaching
How were you referred to Modern Psychiatry?*

Insurance Company DirectoryPsychology TodayGoogle Search/Modern Psychiatry WebsiteInstagram AdWeb MDPrimary Care DoctorFamily/FriendOther
Which provider would you like to see? If no preference, type “first available.”
Name of Provider or “First Available”
Please be advised that medications with addictive potential may require in-person visits, at the discretion of the prescriber, to comply with federal and state regulations.*

I acknowledge.
Person Completing Form*

PatientParent/Legal GuardianOther
Patient Name*

First NameLast Name
Gender*
Date of Birth*

MonthDayYear
Date
Name of Person Completing Form*
If self type "self"
Phone # of Person Completing Form*
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient Phone #*
Patient Alternate Phone #*
Patient Email Address*
example@example.com
Preferred Method of Contact (check all that apply)*

Phone CallEmailText message (text messaging fees may apply)Unknown
Race
Ethnicity
Marital Status *
Emergency Contact Name*
Relationship to Patient*
Phone #*
Reason patient is seeking services. Include any current/past diagnoses. ***Please note that Modern Psychiatry cannot provide emergency psychiatric treatment or detox services. Please go to your nearest emergency room or call 911. *
Parent/Guardian Information

(Complete if patient is under the age of 18 or is an adult with POA/legal guardian)
1st Parent/Guardian Name

First NameLast Name
Relationship to Patient
Parent/Legal Guardian Address (if different than patient)

Street Address

Street Address Line 2

CityState

Zip Code
1st Parent/Legal Guardian Phone #
1st Parent/Guardian Email (if different than above)
example@example.com
2nd Parent/Guardian Name

First NameLast Name
Relationship to Patient
Parent/Legal Guardian Address (if different than patient)

Street Address

Street Address Line 2

CityState

Zip Code
2nd Parent/Legal Guardian Phone #
2nd Parent/Guardian Email (if different than above)
example@example.com
Insurance Information
How many health insurance plans is the patient covered by?

Patient has only 1 health insurance plan.Patient has 2 health insurance plans (primary and secondary coverage).Patient has no health insurance and will be considered "self pay."Worker's Comp Insurance
Primary Insurance Policy Holder Relationship?

SelfParent/Legal GuardianSpouse
Name of Insurance Company*
If no Insurance type “self-pay”
Subscriber/Member ID Number*
Group Number
SSN # (Medicare/Medicaid Recipient Only)
Primary Subscriber's Name

First NameLast Name
Subscriber's Date of Birth

MonthDayYear
Date
Subscriber's Address (if different than patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload/Take picture of Insurance Card (Front and Back)

For Medicare and Medicaid Recipients:
- Medicare Advantage/Managed Medicaid Plans- Also include a copy of your Medicare Card.
- Medicaid Managed Care Plans- Also include a copy of your State Medicaid Card.
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Upload Photo ID of Patient or Parent/Legal Guardian if patient is a minor*

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**Should your device not support the uploading of files or photos, please email copies of your insurance cards and photo ID to contact@mymodernpsychiatry.com or fax to 732-832-3632.
Secondary Insurance
Secondary Insurance Policy Holder Relationship?

SelfParent/Legal GuardianSpouse
Name of Secondary Insurance Company
Subscriber ID #
Group Number
Subscriber's Name

First NameLast Name
Subscriber's Date of Birth

MonthDayYear
Date
Subscriber's Address (if different than patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload Insurance Card (Front and Back)
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Prescription Benefits card

Please upload the front and back copies of your prescription benefits card.
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Should be Empty:

New Patient Information Forms

Parent/Guardian Information

Insurance Information

Secondary Insurance

Prescription Benefits card