New Patient Screening

New Patient Form

Complete this secure, HIPAA compliant form to determine insurance coverage before we schedule an appointment.
Full Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth *

Month Day Year
Birth Sex *

Male Female
Email *
example@example.com
Phone Number *

Area Code Phone Number
Is it OK to leave a voicemail?

Yes, but no specific information Yes, and may leave specific health information No
Is it OK to leave a voicemail? *

Yes, but no specific information Yes, and may leave specific health information No
Is it OK to text you at this number? *

Yes No
Upload Drivers License or other Identification to verify your identity

Browse Files
Multiple files are allowed. May be: jpg, png, gif, bmp, doc, pdf. Cancel of
If you don't have your drivers license at the moment, you can email it at your convenience to inquiry@telepsychhealth.com Insurance companies, pharmacies, and federal law require us to verify your identity.
Insurance Information
Check box if you do not have insurance:

I do not have insurance and will pay out of pocket
Upload front and back of insurance card

Browse Files
Multiple files are allowed Cancel of
If you don't have your insurance card at the moment, you can email it at your convenience to inquiry@telepsychhealth.com
If you are a dependent of another person for your insurance coverage, please fill in the primary member information:
Primary Insurance Member

First Name Last Name
Primary Member Date of Birth

Month Day Year
Date
How did you hear about us? *
What is the most significant ISSUE for you? *
How can we help you?
Which of the following have you experienced in your lifetime? Check any that have had a significant impact or impairment on your life.

Depression Grief/Loss Anxiety Attention difficulties Traumatic event Irritability Sleep problems Memory problems Panic attacks Eating disorder
What psychiatric DIAGNOSES have you ever received? *
Which of the following TREATMENT OPTIONS are you interested in?

I want to see a therapist and start therapy I want to join group therapy I am considering prescription medications I am considering nonprescription medications All of the above
Are you wanting certain MEDICATIONS prescribed? If so, which ones? *
If so, which ones?
Please note that we do NOT prescribe controlled substances such as Adderall, Ritalin, Xanax, Klonopin, Ativan
Do you need any paperwork completed, such as disability or work release? *

Yes No
What paperwork? *
Please note, a disability evaluation is a specific type of evaluation that we do not perform due to practice restrictions. If you are receiving any money through workers' compensation, you cannot be seen in our practice. By submitting this form, you attest that you are not receiving any money through workers' compensation.
Would you like to be added to our WAITLIST for an earlier appointment?

Yes No
Would you consider a 30 min slot, if one were to open? We often have many more 30 min appt cancellations.

Yes No
Should be Empty:

New Patient Form

Insurance Information