New Patient Intake Packet - Adult

  • Welcome to Conscious Mind Psychiatry!

    We’re truly grateful that you’ve chosen us to be part of your care. It’s a privilege to support you, and we look forward to walking alongside you with compassion and respect throughout your journey. Please take a few moments to complete the paperwork as thoroughly and accurately as possible. Providing detailed information helps us prepare for your visit and ensures your first appointment runs smoothly and efficiently. If you have any questions while filling out the forms, our team is happy to assist you.
  • Type of Service Requested*

  • PATIENT INFORMATION

  • Date of Birth*
     - -
  • Legal Gender*
  • Marital Status*
  • Format: (000) 000-0000.
  • Primary Phone Number Type
  • Format: (000) 000-0000.
  • Secondary Phone Number Type
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  • INSURANCE INFORMATION

  • Will you be using health insurance for your visits?*

  • CASH PAY POLICY

    If you are not presenting with insurance for your visits with Conscious Mind Psychiatry, you will be billed at the self pay rates of $150 New Patient /Intake and $100 Follow Up Visits.  Payment in full is expected at the time of service.

  • Relationship to Subscriber*
  • Date of Birth for Subscriber
     - -
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  • Do you have a Secondary Insurance?*
  • Relationship to Subscriber
  • Date of Birth for Subscriber
     - -
  • Relationship to Subscriber
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  • Date*
     - -

  • MEDICAL INFORMATION

  • Patient Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Do you have any allergies?*

  • AUTHORIZATION FOR RELEASE OF INFORMATION TO FAMILY MEMBERS

    Many of our patients choose to have a spouse, parent, or other trusted person contact our office on their behalf. To protect your privacy in accordance with HIPAA regulations, we cannot share medical, appointment, or billing information with anyone without your written permission. If you would like us to speak with or release information to a family member or other designated individual, please complete and sign this authorization form.
  • Date*
     - -

  • OFFICE POLICIES

  • Date*
     - -
  • Date*
     - -
  • Date*
     - -
  • Date*
     - -
  • Date
     - -
  • Date*
     - -

  • CREDIT CARD AUTHORIZATION

    For your convenience, we offer the option to keep a credit or debit card securely on file to automatically process any outstanding insurance or self-pay balances. This helps ensure timely payment and reduces the need for additional billing statements. Providing a card on file is completely optional, and charges will only be applied in accordance with our financial policy.

     

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