New Patient Registration Form -

Patient Details

First Name

Middle Name

Last Name

Date of Birth

Gender Identity (if different)

Contact Information

Street Address

Apartment or Suite #

City

State

ZipCode

Add Additional Phone Number(s)

Guardianship Information

The Patient is his/her own legal guardian (skip the rest of this section)

Add Guardian(s)

If you are divorced or separated, what are the custody arrangements?

Emergency Contact(s)

Add Emergency Contact(s)

Insurance Information

Patient does not have insurance, or does not wish to have insurance billed for services

Please list all applicable health insurance policies that you have. Please list them in the order of responsibility (i.e., primary coverage should be listed first, then secondary, etc.) Incorrect or missing coverage information may result in claim delays or rejections.

Add Coverage Information

Upload Insurance Card We need a picture of both the front and the back of the card for any applicable health insurance policies. PLEASE NOTE: uploading a card is not a substitute for completion of the insurance information section above.

Add file

Please upload a file

Family Information

No other household members

Add Family Member

Providers

No providers to list

Add Provider

Hospitalizations

No previous hospitalizations

Add Hospitalization

Mental Health Services

No previous mental health/counseling services

Add Mental Health Services

Previous Evaluation/Psychological Testing

Has the patient been previously evaluated by a Psychiatrist, Psychologist or Developmental Specialist?

Yes No (if no, skip the remainder of this section)

If yes, when and with whom?

What was the result?

If you were referred for psychological testing, how might an evaluation help you and/or your child?

Medications

The patient is not currently taking any medications

Add Medication

Allergies

The patient has no documented allergies

Add Allergy

Family Health History

(Please list all known medical conditions as well as who in the family is affected)

Add Condition

Reason for Consultation

Please describe the problem(s)/concern(s) that brought you here:

What are you hoping to learn?

What are your goals for treatment?

Is there any other information you would like to include that isn't asked for elsewhere?

Thanks for trusting us to help you! If at any point you have any questions or concerns about the treatment you receive, please let your therapist know.

Your information will be encrypted.

New Patient Registration Form