New Patient Registration Form

Please correct the errors described below.

Patient Details

Contact Information

Add Additional Phone Number(s)

Guardianship Information

Add Guardian(s)

Emergency Contact(s)

Add Emergency Contact(s)

Insurance Information

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

    Please upload a file

    Family Information

    Add Family Member

    Providers

    Add Provider

    Hospitalizations

    Add Hospitalization

    Mental Health Services

    Add Mental Health Services

    Previous Evaluation/Psychological Testing

    Medications

    Add Medication

    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

    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.

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