Become A Patient | MindPractice Demo

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Become A Patient

Please submit your information below and our team will review your application and contact you with next steps.

Please note: New patients must be 18 years or older.

Source:

Who are you completing this application for? *

Myself
Someone else
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Relationship To Patient *

Parent
Guardian
Child
Spouse/Partner
Case Manager
Therapist
Provider
Other
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First Name of Person Completing Form *

Last Name of Person Completing Form *

Phone of Person Completing Form *

1. How old is the patient? *

0 - 17 years old

18 years old + above

2. Has the patient had auditory, visual hallucinations or paranoid thoughts in the past week? *

Yes

No

Please describe recent auditory or visual hallucinations or paranoid thoughts. *

3. Has the patient used any of the following in the past month: Cocaine, Ecstasy, Methamphetamine, Heroin, Inhalants, Non-Prescribed Pain Killers *

Yes

No

4. Has the patient abused alcohol in the past month? *

Yes

No

How many drinks does the patient have on a typical day? *

5. Has the patient had a suicide attempt or engaged in self-harm in the past two weeks? *

Yes

No

6. Has the patient failed 2 or more medications? *

Yes

No

Treatment of Interest *

Medication Management

TMS

Spravato

Therapy / Counseling

Genetic Testing

Primary Reason For Visit *

Depression
Anxiety
ADHD
PTSD
OCD
Bipolar Disorder
Panic Disorder
Eating Disorder
LGBTQIA+ Support
Other
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In your own words, please describe how we can help. *

How did you hear about us? *

Google Search
Doctor/Therapist Referral
Insurance Directory
Friend
Family Member
Employer
Social Media
Other
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Please enter the name of the provider who referred you. *

Please specify how you heard about us. *

Patient First Name *

Patient Last Name *

Patient Mobile Phone *

Patient Email *

Patient Date of Birth *

Sex Assigned at Birth *

Male

Female

Street Address *

City *

State *

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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ZIP code *

How will you be paying for your visits? *

Self-pay
Insurance
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Primary Insurance *

Aetna
Beacon
Blue Cross / Blue Shield
Cigna
Commercial
Compsych
Elevance Health
Government Other
Humana
Medicaid
Medicare
Supplemental
Tricare
United Healthcare
Other
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Name of Other Insurance *

Primary Insurance ID *

Primary Insurance Group Number *

Are you the primary policy holder? *

Yes

No

First & Last Name of Policy Holder *

Date of Birth of Policy Holder *

Do you have a Secondary Insurance? *

Yes

No

Secondary Insurance *

Secondary Insurance ID *

Secondary Insurance Group Number *

Upload a photo of the FRONT of your Insurance Card(s) *

Upload a photo of the BACK of your Insurance Card(s) *

Upload a photo of the front of your Driver’s License or Other Government ID *

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