Client Appointment Request - BryanPatrick.net

Client Appointment Request
Personal Information Notice

Please be aware that communicating personal information electronically poses a risk to your confidentiality. New Story Behavioral Health uses HIPAA-compliant electronic communication to protect your privacy. New Story Behavioral Health Staff will not disclose any personal information provided on this application form.
Your Full Name

First NameLast Name
Your Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Can we leave a voice message at this number?
Text Messaging Opt-In (SMS Opt-in). By checking this box, I consent to receive SMS (text messages) from New Story Behavioral Health. At any time, you may reply STOP to opt-out or Reply HELP for support. Message & data rates may apply. Messaging frequency may vary. Visit https://www.newstorybehavioralhealth.com/privacy to see our privacy policy and Terms of Service. SMS consent and phone numbers will not be shared with any third parties or affiliates.
Our full privacy policy is located here: https://www.newstorybehavioralhealth.com/privacy
Email Address
example@example.com
We would like to keep you informed of events and services offered by New Story Behavioral Health. Check here to consent to receiving information via email. Emails will be sent to your inbox as standard, unsecured (unencrypted) email. Please take appropriate care to protect your personal privacy. You can unsubscribe from emails at any time.
Please list your city and state of residence.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you seeking services for yourself or someone else?
Name of Your Child Under 18

First NameLast Name
Birthdate of Your Child Under 18

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of the person for which you seek services:

First NameLast Name
Gender of the person seeking services:
What services are you seeking?
How did you hear about New Story Behavioral Health? Select all that apply:

Other
I am interested in reduced-fee services with a New Story Behavioral Health intern.
Comments/Reason for Services
Should be Empty: