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.
Not providers for Medicare, Medicare "Advantage" plans, Medicaid,
Tricare or Scott & White. Self-pay fees would apply.
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)