402-399-9305
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402-399-9305
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402-399-9305
Financial & Insurance
Careers
Contact Us
New Patient Request Form
Please note: if you are an
existing
patient, call the office to schedule.
"
*
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Patient Information
First Name
*
Last Name
*
Date of Birth
*
Month
Day
Year
Age
*
Legal Guardian/POA/Caregiver
Home Phone
Cell Phone
Work Phone
Email Address
*
Home Address
Street Address
Address Line 2
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Reason for Appointment/Referral
*
Referred by
Have you or your family members been seen in this office before?
*
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No
Insurance & Payment Information
Patient Employer
Primary Insurance Carrier
Policy Holder
Insurance ID #:
Secondary Insurance Carrier
Does this visit involve any legal or attorney issues?
*
Yes
No
Please explain
*
Medical History
Prior Psychiatric Care/Treatment
Prior Psychologist/Therapist/Counseling Treatment
Have you ever been hospitalized for mental health care?
*
Yes
No
Please explain where and when
Medication and Drug Information
Are you currently taking any psychiatric medications?
*
Yes
No
Please list medications and prescriber
Are you currently using any illegal drugs (such as marijuana and drinking alcohol to excess)?
*
Yes
No
Please list substances and describe use
*
Date of last use
*
Month
Day
Year
Is there a history of past addiction?
*
Yes
No
Appointment Information
Preferred Appointment Day of Week
*
Check all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Appointment Time
*
Check all that apply.
Morning
Afternoon
Preferred Provider
Optionally request a specific provider.
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