Patient Health and Insurance Information

Basic Information

Full Name *

Email Address *

Preferred Name/Nickname

Date of Birth *

Phone Number

Pronouns

She/Her He/Him They/Them

Address

Employment Status

How did you hear about us?

Self Mental Health Therapist PCP / Family Physician Other:

Emergency Contact Details

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact Address*

Mental Health Information

Primary Mental Health Concerns (in your own words) *

I. Reason for Seeking Care

What brings you here today? (Select all that apply)

Address specific symptoms (e.g., anxiety, depression) Cope with a recent life stressor Explore past experiences or trauma Improve relationships Personal growth and self-discovery Manage a diagnosed mental health condition Explore psychedelic integration Other:

Please elaborate on your reason for seeking care *

Services Requested

What services are you interested in? (Select all that apply)

Medication Management Talk Therapy Transcranial Magnetic Stimulation Spravato Neuropsychiatric Testing ADHD Services Other:

Preferred Location

Select your preferred location:

Healthcare Information

Primary Care Provider

Provider Name

Practice Name

Contact Number

Pharmacy

Name / Phone / Address

Insurance Information

Relation to Patient *

Policy Number *

Insurance Provider *

Name of Insured Person *

Do you have secondary insurance?

Yes No

Policy holder DOB*

Second Insurance Name

Patient Health and Insurance Form

Basic Information

Emergency Contact Details

Mental Health Information

I. Reason for Seeking Care

II. Risk Assessment

Services Requested

Preferred Location

Healthcare Information

Primary Care Provider

Pharmacy

Insurance Information

Patient Health and Insurance Form

Basic Information

Emergency Contact Details

Mental Health Information

I. Reason for Seeking Care

II. Risk Assessment

Services Requested

Preferred Location

Healthcare Information

Primary Care Provider

Pharmacy

Insurance Information

Your Safety Is Important