NEW PATIENT INFORMATION
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1.
ARE YOU FILLING OUT THIS FORM FOR YOU OR SOMEONE ELSE?
(Required.)
Myself
Other (please specify)
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2.
ARE WE “IN NETWORK” WITH YOUR INSURANCE?
(Required.)
I verified ‘Peaceful Minds Counseling’ IS in network with my Insurance Provider
‘Peaceful Minds Counseling’ IS NOT in network with my Insurance Provider, I am interested in Out of Pocket Cost
3.
IF YES TO INSURANCE, WHAT INSURANCE DO YOU HAVE?
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4.
WHAT ARE YOU LOOKING TO ADDRESS IN COUNSELING?
(Required.)
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5.
ARE YOU OPEN TO APPOINTMENTS WITH AN INTERN?
(Required.)
Yes
No
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6.
ARE YOU OPEN TO TELEHEALTH (VIDEO) APPOINTMENTS WITH A MALE PROVIDER?
(Required.)
Yes
No
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7.
YOUR NAME:
(Required.)
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8.
YOUR EMAIL ADDRESS:
(Required.)
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9.
YOUR PHONE NUMBER
(Required.)