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New Patient
FAQ
Prospective Patient Form
If you are interested in a new patient appointment, please fill out this form as completely as possible. If you can't provide the requested information type "unknown" or "declined" but be aware that this may delay your ability to make an appointment.
Fill out each section of the form and click NEXT to move to the next section of the form.
What Insurance Carrier(s) do you have?
Primary:
Cash
Aetna
American Behavioral
Arizona Care Network (PPO/PCP)
Beacon
Blue Cross/Blue Shield Excl. Net. Alliance/Acclaim
Blue Cross/Blue Shield Exclusive Net. BC/BS Select
Blue Cross/Blue Shield PPO Group/Neighborhood
CHAMPVa Veterans Administration
Cigna
Compsych
Gilsbar
HMC Healthworks
Holmon Group
Humana/Lifesynch
Magellan Commercial Network
Mayo Clinical Health Solutions
Meritain
MHN AM Better AZ Complete Care
Mines
Summit Healthcare
Tricare (via MHN)
Triwest VA/Healthcare Alliance
United Healthcare UBH/Optum General
United Medical Resources Healthcare
Medicare
AHCCCS
Medicaid
Other
Secondary (if any):
Cash
Aetna
American Behavioral
Arizona Care Network (PPO/PCP)
Beacon
Blue Cross/Blue Shield Excl. Net. Alliance/Acclaim
Blue Cross/Blue Shield Exclusive Net. BC/BS Select
Blue Cross/Blue Shield PPO Group/Neighborhood
CHAMPVa Veterans Administration
Cigna
Compsych
Gilsbar
HMC Healthworks
Holmon Group
Humana/Lifesynch
Magellan Commercial Network
Mayo Clinical Health Solutions
Meritain
MHN AM Better AZ Complete Care
Mines
Summit Healthcare
Tricare (via MHN)
Triwest VA/Healthcare Alliance
United Healthcare UBH/Optum General
United Medical Resources Healthcare
Medicare
AHCCCS
Medicaid
Other
Insurance Information: (please provide the following numbers):
Insurance ID:
Group ID:
Secondary Insurance Information: (if applicable):
2nd Insurance ID:
2nd Group ID:
Please complete the insurance section before clicking NEXT.
Patient's Name:
First:
Middle:
Last:
Preferred 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
Is the patient pregnant or post-partum?
No
Yes
The Patient's Address:
Street Address:
Address Line 2:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip code:
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:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
The following information is for the secondary insurance subscriber:
If same as the patient check this box:
(only one of these boxes can be checked at a time)
If same as the first subscriber check this box:
(only one of these boxes can be checked at a time)
2nd Subscriber's Name:
2nd Subscriber's Gender:
Male
Female
Patient's Relationship to 2nd Subscriber:
Select One
Spouse
Domestic Partner
Child
Self
Other
2nd Subscriber's Birth Date:
2nd Subscriber's SSN:
2nd Subscriber's Address, City, State & Zip:
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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:
Please complete the Demographics section before clicking NEXT.
Are you being discharged from a hospital and need an urgent appointment? Yes:
No:
We will need a copy of the record from that hospitalization or evaluation for your appointment.
Please answer the discharge question before clicking NEXT.
Please answer the following questions to see if you would benefit from our Advanced Depression Treatment program.
1. Were you being treated for depression or suicidal thoughts/behaviors?
Yes:
No:
2. Have you been treated with 4 or more antidepressant medications?
Yes:
No:
3. Have you tried counseling/therapy?
Yes:
No:
3a. If no, did you participate in counseling while inpatient?
Yes:
No:
4. Have you been diagnosed with a psychotic disorder (ever) or substance abuse (within the last 6 months)?
Yes:
No:
5. Do you have a medical provider who prescribes your psychiatric medication?
Yes:
No:
5a. If yes, are you looking for a new provider or are you in need of an urgent appointment but plan on following up with your regular provider?
Yes:
No:
Please answer all questions before clicking NEXT.
Check the reason(s) and/or interest(s) for the desired appointment?
Depression
Post-Partum Depression
Hospital Discharge
ADHD
Anxiety/Stress
Bipolar Disorder
Behavioral Disorder
Sleep Problems
PTSD
OCD
Other Issues
Advanced Depression Treatment program candidates will get a priority appointment.
Please select at least one reason before clicking NEXT.
Please answer the following questions to see if you would benefit from our Advanced Depression Treatment program.
1. Does your depression cause significant impairment or distress in at least one area of life
(work, school, marriage, social, family, etc.)?
Yes:
No:
2. Have you been dissatisfied with the results of antidepressant medication treatment?
Yes:
No:
3. Have you tried counseling/therapy?
Yes:
No:
3a. If no, are you interested in non-medication options for depression other than therapy?
Yes:
No:
4. Have you been diagnosed with a psychotic disorder (ever) or substance abuse (within the last 6 months)?
Yes:
No:
4a. If no, are you interested in non-medication options for depression other than therapy?
Yes:
No:
Please answer all the questions before clicking NEXT.
Please Provide your Contact Information. (must enter only valid phone and email address)
Phone Number:
Phone Type:
Home
Mobile
Work
Email Address:
Retype Email:
The email addresses must match.
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
Choose Your Preferred Location(s):
Chandler
GConRay
Gilbert
GilbertCounselors
Phoenix
Any Office
What kind of provider do I need?
Doctor/Nurse Practitioner: I need a diagnosis and possibly medication.
Advanced Treatment: I am interested in superior treatment options that can help patients who are not satisfied with
conventional treatments (medication and therapy) or want to avoid medications.
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
Richard Burton MD
Ann Marie Casey PMHNP
Tara Clark DNP PMHNP
Tallan DePriest DO
Rachel Eager PMHNP
Makenna Francis PMHNP
Jason Friday MD
Raymond Hippe PMHNP
Amanda Lowry PMHNP
Andrew Lyons FNP
Melinda Marra PMHNP
Roger Mayorga PMHNP
Mark McCoy PMHNP-BC
Lisa Pace Navarro PMHNP
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.