Patient Registration

Thank you for choosing Behavioral Solutions of Texas, LLC as your mental health care provider. Our goal is to provide you with the best possible service that will help you reach your goals.

Physician & Office Location

Patient Information

Reason For Visit

Legal First Name

Middle Initial

Legal Last Name

Preferred Name

Date of Birth

Social Security Number

Street Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Employer Name

Occupation

Who shall we contact in case of an emergency?

First Name

Last Name

Home Phone

Cell Phone

Work Phone

Payment Information

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Account Responsible Information

Copy information from the Patient Information Section

First Name

Middle Initial

Last Name

Date of Birth

Social Security Number

Home Phone

Cell Phone

Work Phone

Medical Insurance Information

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Referral Information

Please tell us how you heard about our services

Description\Name

Medications

Add Another Medication

Review and Submit

You may print a copy of this document directly from your web browser or you may request a copy from our receptionist. By checking the box below, I acknowledge that I have reviewed the Patient Information Packet in its entirety and that I have the right to ask questions regarding the information contained therein prior to initiating treatment.

Privacy Statement

I have read the Privacy Statement

Once you have completed the Patient Intake Form you will need to login to the Patient Portal in order to complete any additional documents. To access the Patient Portal create a UserName and Password(Password must be a minimum of 8 characters).

Patient UserName & Password

User Name:

Password:

Confirm Password:

Make changes above, or if you are ready, please click the submit button below to proceed.

Your information will be encrypted.