New Patient Telehealth Appointment Request

New Patient Telehealth Appointment Request

Appointment requests are reviewed during business hours and are not confirmed until intake review, insurance verification, and scheduling approval are completed, including weekend requests for Monday appointments.
New Telehealth Psychiatric Evaluation
Patient's Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person completing the form
Person completing the form - Name (if other than patient)

First NameLast Name
Emergency contact full name

First NameLast Name
Emergency contact relationship to patient
Emergency contact phone number
Please enter a valid phone number.Format: (000) 000-0000.

How will you be paying for services?
Horizons Mental Wellness LLC is not enrolled as a Medicaid provider. If Medicaid is your primary or secondary insurance, you may be referred to a participating provider.
Insurance company
Member ID
Upload insurance card front

Cancelof
Upload insurance card back

Cancelof
Is the patient the primary insurance policyholder?
If the patient is covered under another person's insurance plan (such as a parent, spouse, or guardian), please enter the primary policyholder's information below exactly as it appears with the insurance company.
Primary policyholder's full name
Primary policy holder relationship to patient
Primary policyholder's date of birth

MonthDayYear
Date
Primary Policyholder's Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Do you have secondary insurance?
Upload secondary insurance card front

Cancelof
Upload secondary insurance card back

Cancelof
Insurance verification is not a guarantee of payment or coverage. Patients remain financially responsible for non-covered services, deductibles, copays, coinsurance, and denied claims.
A government-issued photo ID is required for identity verification and telehealth compliance purposes.

Cancelof
Emergency Disclaimer
Horizons Mental Wellness LLC does not provide emergency services. If you are experiencing a crisis, call 911 or go to the nearest emergency department. For suicidal thoughts, call 911 and/or 988. Messages are not continuously monitoried outside of buisness hours or scheduled appointments.
I understand the emergency disclaimer.

Clinical Intake information

Please provide the following clinical and background information to help us better understand your concerns, symptoms, treatment history, and care needs prior to your appointment.
What is the main reason for your visit?
Please describe any symptoms or concerns.
Referral source - How did you hear about us?
Current Medical Medications
Current Psychiatric Medications
Supplements and Vitamins
Previous Psychiatric Diagnoses
Currently in therapy
Current Therapist Name/Practice and type of therapy (if none, type N/A)
Psychiatric hospitalizations
Current stressors
Preferred Pharmacy
Preferred pharmacy address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code

Policies & Consents

Please carefully review the following policies and consent documents before proceeding. By checking the acknowledgment boxes and signing below you confirm that you have reviewed and agreed to the applicable policies and treatment consents for Horizons Mental Wellness LLC. If you have any questions or need clarification regarding any policy or consent document, please contact the office prior to submitting your appointment request.
Financial Policy
Please review our Financial Policy prior to submitting your appointment request.

Click Here to View the Financial Policy
I acknowledge that I have reviewed and agree to the Financial Policy.
Communication Policy
Please review the Communication Policy prior to submitting your appointment request.

Click Here to View the Communication Policy
I acknowledge that I have reviewed and agree to the Communication Policy.
Cancellation and No Show Policy
Please review our Cancellation and No-Show Policy prior to submitting your appointment request.

Click Here to View the Cancellation & No-Show Policy
I acknowledge that I have reviewed and agree to the Cancellation and No Show Policy.
HIPAA Privacy Practices
Please review our Notice of Privacy Practices (HIPAA Policy) prior to submitting your appointment request.

Click Here to View the HIPAA Privacy Policy
I acknowledge that I have reviewed the HIPAA notice of privacy practices.
Telehealth Consent
Please review our telehealth information and consent prior to submitting your appointment request. This consent outlines the risks, benefits, limitations, privacy protections, emergency procedures, and expectations associated with receiving psychiatric services through telehealth.

Click Here to View the Telehealth Information & Consent
I have reviewed and understand the Telehealth Information & Consent and agree to receive services via telehealth from Horizons Mental Wellness LLC and its authorized clinicians.
Controlled Medication Policy Acknowledgement
Certain medications may require additional monitoring, pharmacy verification, identity verification, urine drug screening, treatment agreements, or more frequent follow-up appointments in accordance with clinical judgment and state/federal regulations.
I understand and acknowledge the controlled medication policy.
Consent to Treatment
I consent to treatment with Horizons Mental Wellness LLC. For minors, I am the parent or legal guardian and have authority to consent to treatment for the minor patient. I understand that outcomes cannot be guaranteed and that I may withdraw consent in writing at any time.

By signing below, I acknowledge that I have reviewed and agreed to the applicable policies, notices, and treatment consents provided by Horizons Mental Wellness LLC. I certify that the information submitted is accurate and complete to the best of my knowledge.
I certify that I am authorized to consent for treatment and complete this form.
Printed Full Legal Name
Patient Signature
Signature Date

MonthDayYear
Date
Should be Empty:

New Patient Telehealth Appointment Request

Emergency Disclaimer

Clinical Intake information

Financial Policy

Communication Policy

Cancellation and No Show Policy

HIPAA Privacy Practices

Telehealth Consent

Controlled Medication Policy Acknowledgement

Consent to Treatment