Redemption Psychiatry - Prospective Patient Form

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:

Secondary (if any):

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:

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: 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 Birth Date:      Subscriber's SSN:
     Subscriber's Address, City, State & Zip:
  Address:

    City: State: 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 Birth Date:      2nd Subscriber's SSN:
     2nd Subscriber's Address, City, State & Zip:
  Address:

    City: State: 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:
  Email Address:   Retype Email:

The email addresses must match.

       Your Preferred Contact Method:
     Preferred Time(s) for Appointment: Morning            Afternoon
     Preferred Day(s) for Appointment: Monday            Tuesday            Wednesday            Thursday            Friday            Saturday

Choose Your Preferred Location(s):

Arrowhead

Chandler

Gilbert

Metro

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:

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