New Patient Application

Park Valley Behavioral Health Care

The Maxwell Centre, Suite 500

32 20th Street

Wheeling, WV 26003

Phone: (304) 218 - 2023 Fax: (304) 907-4259

Please note our accessible parking and entrance

on the Market Street side of the building.

New Patient Application

Thank you very much for your interest in our services!

Feel free to ask for assistance with anything you do not understand.

Services:

General Psychiatry and Psychotherapy

Child and Adolescent Mental Health Services

Perinatal (Pregnancy & Postpartum) Mental Health Services

Certified medication management and therapy services

Medication Assisted Treatment (MAT) for Opioid Addiction

Our MAT Program requires participation in therapy and 12 Step Meetings

Note:
- Our prescribers do not treat for pain.
- We do not prescribe controlled substances at first visit.
- Past and present pharmacy records are reviewed.
- We are not accepting new patients seeking legal assistance, disability, FMLA or workers' compensation.
Patient's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*

PsychiatristPsychiatric Physician Assistant (PA)Therapist (Counselor)
Preferred Provider Name (If known)
Feel free to check out the Meet the Team page on our website to get to know our providers and to see who is currently accepting new patients!
YesNo
YesNo
Please describe the symptoms your child is experiencing (Do not include past or current diagnoses. Tell us about your child's symptoms now and how they are affecting your lives):*
Please describe the symptoms you are experiencing (Do not include past or current diagnoses. Tell us about your symptoms now and how they are affecting your life):*
YesNo
Note: We are not accepting new patients seeking legal assistance, disability, FMLA or workers' compensation. We will consider assisting patients seeking the above benefits only for established patients who have actively been participating in treatment for a minimum of 1 year.

Primary Insurance - Insurance information is required to schedule an appointment

(If no insurance, type "self pay")
Insurance Company:*
ID:*
Group #:
Individual yearly deductible amount:
Dollar amount - please call the customer service number on your insurance card for this information
Insurance effective date:

MonthDayYear
Date
Responsible Party Information (Person who holds the insurance)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you are able to do so, please upload your insurance card
Front of Insurance Card
Back of Insurance Card
I hereby certify that the insurance information provided is accurate and currently active.
Signature*
Date*

MonthDayYear
Date
Secondary or Additional Insurance

Leave blank if no additional insurance
Insurance Company:
ID:
Group #:
Individual yearly deductible amount:
Dollar amount - please call the customer service number on your insurance card for this information
Insurance effective date

MonthDayYear
Date
Responsible Party Information (Person who holds the insurance)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you are able to do so, please upload your insurance card
Front of Insurance Card
Back of Insurance Card
I hereby certify that the insurance information provided is accurate and currently active.
Signature*
Date*

MonthDayYear
Date
INSURANCE AUTHORIZATION AND RELEASE:

I authorize the release of any information, including the diagnosis and records of any treatment or examination rendered to me or my dependents during the period of such care to a third party payers (insurance) and/or other health practitioners as requested.

I authorize and request my insurance company to pay directly to the doctor or doctor's group insurance benefits otherwise payable to me.

I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that the patient responsibility is due at the time of service. Any co-pay and past due balance must be paid at the time of service.

By signing this form, I accept and agree to these polices. My signature indicates my consent to treatment for myself or my dependent. I give consent for the doctor to request my medication prescription history from pharmacies for continuity of care.
Signature*

Primary Insurance - Insurance information is required to schedule an appointment

Secondary or Additional Insurance

PLEASE INDICATE ANY PSYCHIATRIC MEDICATIONS YOU(YOUR CHILD) HAVE TRIED IN THE PAST