New Patient Screening Form

Thank you for reaching out to our office! Please fill out the information below about the potential patient. The information will be reviewed and evaluated for consideration for admission to our clinic. Please note we strive to make sure we can provide the appropriate treatment for you and if we are not the best fit for your needs will offer possible referral options.

EMPOWERMENT MENTAL HEALTH LLC

4300 B Street, Suite 410

Anchorage, AK 99503

Office: (907) 231-2333 / Fax: (907) 222-6153

www.empowermentmentalhealth.com

First Name

Middle Name

Last Name

Date of Birth

Contact Email

Contact Phone

Is the potential patient under 18 or have a guardian?

Yes

Parent/Guardian Full Name

How did you find our office? Did someone refer you to us? If so, please list referral source.

Presenting Concerns

Please provide several sentences, without enough detail your screening may not be processed.

Brief Mental Health History

Current Psychiatric Medications and Prescriber

Insurance:

We are in-network with Premera, Blue Cross/Blue Shield, Federal Blue Cross/Blue Shield, Aetna, Meritain, Moda, Tricare, Triwest/VA CCN, and United Healthcare Commercial. We will bill out-of-network insurances. We do not accept Medicaid/Denali Kid Care at this time.

Does the patient have health insurance? If no, you will be considered a self-pay patient.

Yes

Primary Insurance

Secondary Insurance

Tertiary Insurance

Once the above information is completed, click submit to send it to Empowerment Mental Health LLC through confidential messaging. Empowerment Mental Health LLC will review it and contact you for follow up. If you do not hear back from us in 3 business days, please do not do fill out another form, please call our office at 907-231-2333.

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