WELCOME TO ALIGN - New Patient Interest Form
Thank you for your interest to join the ALIGN Family. We are eager to assist you in aligning your mental health goals with your reality while meeting you where you are through Telehealth. Please complete our brief intake form and one of our team members will contact you shortly to schedule your appointment. If you have not heard back from one of our team members within 48 hours(excluding weekends and holidays), please email us at patientcare@myaligninc.com.
Email
*
example@example.com
Name
*
First Name
Last Name
Preferred Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Which of the following most accurately describe(s) you?
*
Male
Female
Non-Binary
Transgender
Intersex
Other
Pronoun Preference?
*
He/Him/His
She/Her/Hers
They/Them/Theirs
Ze/Zir/Zirs
N/A
Social Security Number
*
Marital Status
*
Single
Partnered
Married
Legally Separated
Divorced
Widowed
If the patient is under the age of 18 years, please enter the Parent/Legal Guardian/Responsible Party Name, Date of Birth, Social Security Number and Phone Number
*
Please upload Current Drivers License or Identification Card (Front and Back)
*
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Other Phone Number(If applicable)
Email
*
example@example.com
How would you like to receive appointment reminders?
*
Text
Phone Call
Email
Do you have insurance
*
Yes
No
Do you have Medicaid?
*
Yes
No
What is your Primary Insurance Plan? (Type Self Pay if you are Self Pay)
*
Primary Insurance Member/Subscriber ID
*
Primary Insurance Group ID
*
Primary Insurance Card (Front and Back)
*
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What is your Secondary Insurance Insurance Plan? (Type N/A If not applicable)
*
Secondary Insurance Member/Subscriber ID
Secondary Insurance Group ID
Secondary Insurance Card (Front and Back)
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Psychiatric Presentation
Please provide information about your current psychiatric presentation.
Have you seen a psychiatric provider before?
*
Yes
No
Other
Please explain why you are currently seeking services
*
Are you experiencing any of the following? (Check all that apply)
*
Auditory Hallucinations (Hearing Things)
Decreased Appetite
Decreased functioning at one or more: Home, Work, School
Difficulty Focusing or Concentrating
Financial Instability
Homicidal Thoughts
Hypersomnia (Sleeping to much)
Increased Anxiety
Increased Appetite
Increased Depression
Insomnia (Cannot sleep)
Irritability/Anger
Low Interest in Activity
Low Motivation
Mood Lability
Paranoia (I.E. people are out to get you, people are listening to your conversations)
Racing Thoughts
Self-Harm
Suicidal Thoughts
Unstable Housing
Visual Hallucinations (Seeing Things)
Please provide a CURRENT LIST of ALL MEDICATIONS. Include Medication Name, Dose, Frequency, and Why It Is Used.
*
Referral Source
How did you hear about us?
*
Patient Referral
Psychology Today
Social Media
Other
Thank you for your responses. Someone will reach out to you within 48 hours(not including weekends or holidays) to identify the next steps. If you were unable to attach your insurance cards or identification card, please email patientcare@myaligninc.com. Also if you have not received any response within the 48 hours as mentioned above, please contact the office at (804)214-6460 or email patientcare@myaligninc.com
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