We Do Not Take Mass Health Standard
NEW PATIENT INTAKE FORM:
Legal Name: Must put legal name for billing/insurance purposes
First Name
Last Name
Preferred Name:
Enter Patient Date of Birth
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Policy Name & ID Number:
If patient is a minor, enter guardian's name:
Insurance Subscribers Name and Date of Birth, if different than Patient.
Secondary Insurance? If Yes, List Policy Name and Number
What are you seeking services for? Meds, Therapy, TMS?
List current medications and who prescribes them:
Have you had substance use or psychiatric inpatient treatment?
I declare that the info I provided is accurate and complete: Please add initials below:
Submit
Should be Empty: