NEW PATIENT APPOINTMENT REQUEST

NEW PATIENT APPOINTMENT REQUEST
Date*

MonthDayYear
Date
Name*

First NameLast Name
SSN*
Date of birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Text?*

YesNo
Contact name

First NameLast Name
Contact Number

Area CodePhone Number
Relationship
Is this a foster child?*

YesNo
How did you find us?*
Referred by:
Phone Number

Area CodePhone Number
Primary Insurance*
Insurance ID Number*
Insurance Group Number*
Primary Subscriber Name*
Date of birth *

MonthDayYear
Date
Secondary Insurance
Insurance ID Number
Insurance Group Number
Secondary Subscriber Name
Date of birth 2

MonthDayYear
Date
Do you want meds?*

YesNo
Talk Therapy?*

YesNo
Do you want TMS?*

YesNo
Provider Requested
Reason for Treatment
Have you received mental health services in the past 3 years?*
If yes, where and who do you see?
Reason for changing
Have you ever been hospitalized for psychiatric reasons?*

YesNo
If yes, why?
Do you use drugs/alcohol?*

YesNo
Have you received substance abuse treatment?*

YesNo
Are you court ordered for treatment?*

YesNo
Are you on or applied for disability?*

YesNo
Are you on any Registries?*

YesNo
If yes, which One?
Current psychiatric medications
Notes
IF PATIENT IS 17 AND UNDER, A LEGAL GUARDIAN MUST BE PRESENT AT THE FIRST APPOINTMENT. STEP-PARENTS, GRANDPARENTS DO NOT COUNT AS LEGAL GUARDIANS UNLESS THEY HAVE LEGAL DOCUMENTATION.
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