Central Texas Mental Health - New Patient Online Request Form

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New Patient Online Request Form
*Required Fields

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Gender *

Male

Female

Other

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 *

City *

State *

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.

Yes

Insurance Carrier
We accept "Traditional" Medicare and Tricare "Standard", but not Medicare "Advantage" plans, Humana Tricare (PRIME), Medicaid, Scott & White, or Ambetter at this time.

Insurance Carrier Phone Number - More Information 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

OCD

Sadness and/or Depression

PTSD

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)?

Yes

Current or Recent Psychiatric Medications List (please include mg strength and how many doses per day)