New Patient Form
Are you currently part of a DHS case, custody battle, divorce proceedings or any other ongoing legal case?
*
YES
NO
If yes, please explain.
Are you currently experiencing and /or are a victim of domestic violence?
*
YES
NO
Patient Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Home Phone
*
-
Area Code
Phone Number
Marital Status
Single
Married
Divorced
Widowed
Employment
Employed
Unemployed
Disabled
Retired
Student
Emergency Contact Information
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship
Insurance Information
Insurance
*
Blue Cross & Blue Shield of Oklahoma
Blue Cross & Blue Shield of Texas
United Health
Cigna
Health Choice
Group Number (IF ANY)
Policy Number
*
Are you currently taking prescription medication?
Yes
No
Mental Health History
Why you are seeking treatment?
What do you expect from this counselling?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Yes
No
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Month
-
Day
Year
Date
Signature
Clear
Submit
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