Registration

Please use this link to download a PDF version of the form.

Date

Information

Last Name

First Name

Middle

Date of Birth

Age

Gender

Male

Female

Address

City

State

Zip

Phone

Cell

Work

Ext.

Insurance Information

Subscriber

Name of Subscriber

Primary Ins

Group #

Managed Plan Effective Date

Co-pay =$

Policy #

Number of out-patient Mental Health visits /sessions used during calender year

Policy #

# of Sessions in Benefit Plan

Secondary Ins

Group #

Dates of sessions

Authorization to Release Protected Health Information to Insurance Company

Name (Printed)

Date of Birth

Referral Information

How did you hear about us?

Have you been given a diagnosis?

Name of Diagnosing doctor/clinician

Year(s) treated

What type of treatment have you sought for the diagnosis?

Are you currently on any psychotropic medication? Anxiety? Mood stabilizer? Depression Medication?

Current Medications/Dose

Who prescribes the medication (PCP/Psychiatrist?

*** For coordination of care purposes:

May I contact the prescriber?

Yes

Contact number for treating prescriber

(If answers are all “no” to the above questions please answer, the following question)

Reason for Seeking Treatment