Request for Psychiatric Services

Request for Psychiatric Services

Please complete this secure request form for A Helping Hand Inc. Provide your contact, insurance, referral, service, and acknowledgment details. This form is not monitored continuously and should not be used for emergencies.
Patient Information
Patient's Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Age
Patient's Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Email Address
example@example.com
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
School or College (if applicable)
Is the patient under 18 or represented by a legal guardian?
Parent or Legal Guardian's Full Name

First NameMiddle NameLast Name
Relationship to Patient
Parent or Legal Guardian's Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent or Legal Guardian's Email Address
example@example.com
Insurance Information
Insurance Provider
Member ID Number
Group Number
Policyholder Full Name

First NameMiddle NameLast Name
Insurance Card (Front and Back)

Cancelof
Referral Information
How did you hear about A Helping Hand Inc.?
Referring person or organization
Best days or times to contact you
Preferred method of contact
Requested Psychiatric Service
Requested Psychiatric Service
Reason for Request
Currently receiving psychiatric treatment elsewhere?
Acknowledgments
This form is not monitored continuously and should not be used for emergencies. If you or someone else is in immediate danger, call 911 or go to the nearest emergency room.
Consent to Contact
Accuracy Confirmation
Appointment Disclaimer
Should be Empty:

Request for Psychiatric Services

Patient Information

Insurance Information

Referral Information

Requested Psychiatric Service

Acknowledgments