Welcome to Holistic Healing Psychiatry
PATIENT INFORMATION
Full Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Sex
*
Please Select
Male
Female
N/A
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Current Address
Necessary for insurance verification
Street Address
*
Street Address
City
*
State
*
Zip code
*
Insurance Information
Appointment will be subject to insurance verification to determine if provider is in-network.
How will the client pay?
*
With insurance
Out-of-pocket
Insurance Company
*
Type "N/A" for out-of-pocket payment
Policy Holder's Name (if not self)
First Name
Last Name
Member ID
*
Type "N/A" for out-of-pocket payment
Group number
*
Chief Complaint | Reason for your visit
*
Briefly explain your primary issue or symptom why you are seeking psychiatric care.
How can we best reach you?
Text message
Phone call
Email
How did you hear about us?
Please Select
Doctor/Therapist Referral
Patient Referral
Google Ads
Social Media (Facebook & Instagram)
Others
Others (Please specify)
Please upload images of your insurance card (front and back).
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