Back to Central Texas Mental Health
New Patient Online Request Form
Patient First Name *
Patient Last Name *
Patient Date of Birth *
Patient Gender *
If Other - Describe
Patient Drivers License
Patient SSN *
Why do we need this?
Your Insurance company may require this information when we call to verify your enrollment and benefits.
Patient Physical Address *
District of Columbia
Zip Code *
Best phone number to reach to set up appointment *
Best email to reach to set up appointment *
Do you have insurance?
If "Yes", please fill out the remaining insurance form fields.
We accept "Traditional" Medicare and Tricare "Standard", but not Medicare "Advantage" plans, Humana Tricare (PRIME), Medicaid, or Scott & White at this time.
Insurance Carrier Phone Number -
Insurance Carrier Phone Number (on the back of your insurance card). Please submit the one for Providers and/or Behavioral Health so we can call them.
Insurance Policy Holder / Subscriber Name
Insurance Policy Holder / Subscriber Date of Birth
Insurance ID Number
Insurance Group Number
Insurance Authorization Number (Optional)
Chief reason(s) for seeking help (check all that apply) ?
Interested in TMS Treatment
Anxiety and/or Panic
Sadness and/or Depression
Mood Swings and/or Bipolar
Recent Suicide Attempts
Substance Abuse (Alcohol or Drugs)
Recent Thoughts of Suicide
Anger and/or Irritability
Recent Psychiatric Hospitalization
Focus and/or ADD/ADHD
Recent Inpatient Substance Rehabilitation
Schizophrenia/Schizoaffective and/or Psychosis
Recent Leave or Disability From Work
Stable, But Need New Prescriber
Never Taken Psychiatric Medications
Optional: Can you be available in
1 - 2 hours
on short notice for an appointment (flexible schedule)?
Current or Recent Psychiatric Medications List (please include mg strength and how many doses per day)