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? *

Relationship To Patient *

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

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

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

Yes

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

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

Yes

Treatment of Interest *

Medication Management

TMS

Spravato

Therapy / Counseling

Genetic Testing

Primary Reason For Visit *

In your own words, please describe how we can help. *

How did you hear about us? *

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

ZIP code *

How will you be paying for your visits? *

Primary Insurance *

Name of Other Insurance *

Primary Insurance ID *

Primary Insurance Group Number *

Are you the primary policy holder? *

Yes

First & Last Name of Policy Holder *

Date of Birth of Policy Holder *

Patient's Relationship to Policy Holder *

Do you have a Secondary Insurance? *

Yes

Secondary Insurance *

Secondary Insurance ID *

Secondary Insurance Group Number *

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

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

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

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

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

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

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I consent to receive non-marketing text messages from MindPractice Demo about my appointment reminders and support requests. Message & data rates may apply.

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Austin, TX 78744

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