psychatlanta.com - New Patient Request Form

New Patient Request Form
We do not see patients under the age of 21. Please consult your primary care physician or insurance for a Pediatric Psychiatry referral.
Full Name
First NameLast Name
Home Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date of Birth
MonthDayYear
Date
Age*
Type of Treatment Sought*
Please visit here for Therapy.
Seeking Help For:
Type of Payment
Insurance Company Name*
*If your card states that your mental health benefits are provided by another company please enter both names here. For example: Cigna is on the front of your card, but on the back it says mental health: Optum.
Insurance Claims Address*
*Located on the back of your insurance card. Please enter the claim/mailing address for your mental health benefits.
We encourage you to contact your insurance company to verify your mental health benefits and to be sure that your provider is in network with your current insurance provider.
Primary Insurance Holder
Insurance Member ID
Relation to Insured
Cell Phone
Area CodePhone Number
Is it ok to send text and leave voice mails on this number?
YesNo
Home Phone
Area CodePhone Number
Is it ok to send text and leave voice mails on this number?
YesNo
Email
example@example.com
Is it ok to mail reminders or information to this email address?
YesNo
Have You Been Seen at Psych Atlanta Before?*
YesNo
Who Did You See? What Year?
Would You Like To Request A Specific Provider?*
YesNo
If yes, who?
Michael Banov, M.D.Marla Fleming, APRNKaren Greenwood, APRNNamita Patel, APRNDaniel Jay, M.D.Dr. Dennis Barton M.D.
Which office would you like to be seen?*
Referred from:
Psychatlanta.comInsuranceFriendPhysicianTherapistInternetFamily MemberOther
Current Diagnosis:
DepressionAnxietyBipolar DisorderAttention DeficitEating DisorderSubstance AbuseThought DisordersPersonality DisorderNoneOther
Have you had testing?
YesNo
Do you have your test results?
YesNo
Do you remember when you had testing?
Past Mental Health Hospitalization?
YesNo
When?
Where?
Current Mental Health Medication List
Help your doctor with your medication history by visiting www.pastmeds.com
If you are currently not on any medications, please check the box.
Legal Issues Or Applying For Disability?
YesNo
Are you interested in participating in a research study?*
We can not guarrantee you can get disability paperwork at your initial assessment.
Any Other Information That May Be Helpful
Which office would you like to be seen?
MariettaRoswellEither
Should be Empty: