Appointment Request Form

Name of Potential Client

Date of Birth

Name of Parent/Guardian (if potential client is a minor)

Email address

Phone Number

Address (Street)

City

State

Zip Code

Insurance Provider

Member/ Subscriber ID #

Policy Holder

Phone # for Verification of Benefits/ Provider Services

Usually located on the back of your insurance card

Address associated with your insurance (if different than address listed above)

Secondary Insurance Provider (If Applicable)

Member/Subscriber ID #

Phone # for Verification of Benefits/ Provider Services

Usually located on the back of your insurance card

Secondary Insurance Policy Holder (If Applicable)

IF YOU HAVE MEDICAL ASSISTANCE: 10-Digit State ID Number

I am seeking therapy services

I am seeking a neuropsychological evaluation/testing

I am seeking a court-ordered evaluation or evaluation for SSI/SSDI

Referral Concern(s)

Referral Source

Recommended to a specific clinician

Please check any box that applies to the potential client

I have experienced trauma

I have had or currently have struggled with substance use problems

I have been involved in legal issues

I have had suicidal thoughts

I have been hospitalized for a psychiatric concern

If you checked yes to any of the questions above, please explain...

Have you been given a mental health diagnosis in the past?

Yes No

If you answered yes to the question above, please explain...

Have you received mental health treatment in the past?

Yes No

If you responded yes to the question above, please explain...

Current medication(s) and psychiatrist (if applicable)

Current Primary Care Physician (PCP)

Has anyone in your family been given a mental health diagnosis?

Days of the week I'm available for appointments Please note that many of our clinicians do NOT work evenings or weekends and there is limited availability for evening and weekend appointments.

Monday

Tuesday

Wednesday

Thursday

Friday

Weekends

Times I am available for appointments

Mornings

Afternoons

Evenings

Appointment Request Form

Allegheny Mental Health Associates