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New Patient Form

Use this page to capture patient information and receive in email.

1. First Name: *This question is required.

2. Last Name: *This question is required.

3. Email: *This question is required. This question requires a valid email address.

4. Phone: *This question is required.

Please provide your address:

5. Street *This question is required.

6. City *This question is required.

7. State *This question is required.

8. Zip Code *This question is required.

9. DOB: *This question is required.

10. Social Security Number

11. Race: *This question is required.

12. Ethnicity: *This question is required.

13. Emergency Contact Name:

14. Emergency Contact Phone

15. Emergency Contact Relationship

16. Who is your primary care physician? *This question is required.

17. If you are working with a psychiatrist, please provide their name? *This question is required.

18. If you are working any other health care professionals (i.e., OBGYN, Chiropractor, Therapist, Pain Specialist, etc.), please provide his or her name and specialty (e.g., Dr. Jane Smith - OBGYN). *This question is required.

19. How did you hear about us?

20. If you are being referred by a therapist, psychiatrist, police department, probation officer, shelter, re-entry service, or hospital, please provide their name.

21. Have you been a client before?

22. What program are you interested in?

23. How would you like to pay for treatment? *This question is required.

24. If using Insurance, who name is the policy under?

25. Date of Birth of the Policy Holder?

26. What is the name of the Insurance Company?

27. What is your Subscriber ID or Member ID?

28. What is the phone number for your insurance? (usually on the back of the card)

29. What is the name of the Pharmacy and address where you want your prescriptions filled?

29. Additional Information if needed.