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402-399-9305
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Contact Us
New Patient Request Form
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Patient Information
First Name
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Last Name
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Date of Birth
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Day
Year
Age
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Legal Guardian/POA/Caregiver
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Email Address
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Reason for Appointment/Referral
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Have you or your family members been seen in this office before?
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Insurance & Payment Information
Patient Employer
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Policy Holder
Insurance ID #:
Secondary Insurance Carrier
Does this visit involve any legal or attorney issues?
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Please explain
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Medical History
Prior Psychiatric Care/Treatment
Prior Psychologist/Therapist/Counseling Treatment
Have you ever been hospitalized for mental health care?
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Yes
No
Please explain where and when
Medication and Drug Information
Are you currently taking any psychiatric medications?
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Yes
No
Please list medications and prescriber
Are you currently using any illegal drugs (such as marijuana and drinking alcohol to excess)?
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Yes
No
Please list substances and describe use
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Date of last use
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Month
Day
Year
Is there a history of past addiction?
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Yes
No
Appointment Information
Preferred Appointment Day of Week
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Monday
Tuesday
Wednesday
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Friday
Preferred Appointment Time
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Morning
Afternoon
Preferred Provider
Optionally request a specific provider.
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