Patient's Name:  

     Patient Birth Date:       Age:     SSN:      Marital Status: Single Married Divorced Partnered Legally Separated Widowed Other

          What is the sex of the patient?        Male                 Female

      The Patient's Address: 
      Street Address:   
      Address Line 2:   
              City:   State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip code:

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The following information is for the primary insurance subscriber if different from the patient: (if same check this box )
     Subscriber's Name:
     Subscriber's Gender: Male           Female
     Patient's Relationship to Subscriber: Select One Spouse Domestic Partner Child Self Other
     Subscriber's Birth Date:        Subscriber's SSN:
     Subscriber's Address, City, State & Zip:   
  Address:

    City:   State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip:

      Who referred you to our office?     
      Who is your Primary Care Provider?     
      Who is your therapist? (if you have one)     
      Who should be contacted in the event of an emergency?     
      Provide an Emergency Contact Phone Number:     

  Are you being discharged from a hospital and need an urgent appointment?     Yes:       No:                 

  Please Provide your Contact Information. (must enter only valid phone and email address)
       Phone Number:        Phone Type: Home Mobile Work
  Email Address:     Retype Email:  
       Your Preferred Contact Method:   -- no preference -- Phone Email
     Preferred Time(s) for Appointment:   Morning              Afternoon
     Preferred Day(s) for Appointment:  Monday            Tuesday            Wednesday            Thursday            Friday            Saturday

          What kind of provider do I need?
  Doctor/Nurse Practitioner: I need a diagnosis and possibly medication. 

         Select if you prefer a male or female provider?
        Male                 Female                 Either

       If you have a preferred provider select here:      
-- any provider -- Mia Abdouni PMHNP Jason Beals DNP / PMHNP Joaquin Bermudez DO Barbara Browder DNP PMHNP-BC Richard Burton MD Ann Marie Casey PMHNP Tara Clark DNP PMHNP Rachel Eager PMHNP Makenna Francis PMHNP Jason Friday MD Raymond Hippe PMHNP Kionglee Jung DNP / PMHNP Tracy Kouns PMHNP Amanda Lowry PMHNP Andrew Lyons FNP Melinda Marra PMHNP Roger Mayorga PMHNP Mark McCoy PMHNP-BC Lisa Pace Navarro PMHNP Mark Rubin MD Nathan Shaw PMHNP Dallas Smith PA-C Jacob Stein MD Landis Stokum PMHNP Lydia Veratti PMHNP-BC Mark Wesbrock DNP/PMHNP-BC Keith Bradshaw LCSW

       If the provider you want is not in the list above, they practice at a location other than what you have selected.