New Mental Health Patient Registration Form

Name *

First

Last

Date of Birth (MM/DD/YYYY) *

Phone Number *

Email *

Do we have your consent to send you text, voice and/or email messages regarding your appointments? *

Entire Home Address (Street address, Apt #, City, State, Zip Code) *

Medical Insurance Name *

Insurance ID (with Prefix) *

Insurance Group # (if none type in NA) *

Primary Subscriber's First & Last name – Medical Insurance *

Primary Subscriber's Date of Birth (MM/DD/YYYY) *

Reason for Appointment Request *

Please describe the main reason(s) you are seeking mental health support at this time:

Current Symptoms (Check all that apply)

Duration of Symptoms *

How long have you been experiencing these symptoms?

Previous Mental Health Care – Have you seen a therapist, psychiatrist, or other mental health provider before? *

If yes, please provide details (provider name, dates, diagnoses, treatment, etc.):

Current or Past Diagnoses (if known) *

Any mental health diagnoses you’ve received in the past

Current Medications -Are you currently taking any psychiatric medications? *

If yes, please list medications and dosages:

Safety Concerns -Are you currently experiencing thoughts of harming yourself or others? *

If yes, please explain:

Substance Use- Do you currently use alcohol or other substances? *

If yes, what and how often?

Additional Information – Is there anything else you would like us to know?