New Visit Form

    *required field

    Personal Information

    First Name*:

    Last Name*:

    Middle Name:

    DOB*: (MM/DD/YYYY)

    Gender:

    Height*: (Feet and Inches)

    Weight*: (Pounds)

    Address*:

    Zip Code*:

    Primary Phone Number*:

    Secondary Phone Number:

    Email*:

    Marital Status:

    Preferred Pharmacy Name and Phone Number:

    Emergency Contact

    Contact Full Name:

    Phone Number:

    Relationship:

    Work

    Employer:

    Job Title:

    Phone Number:

    Insurance

    Will you be paying by insurance?* If "yes", insurance information below is required.

    Insurance Company:

    Member/Policy Number:

    Group Number:

    Please complete the below if you have a secondary insurance.

    Secondary Insurance Company:

    Secondary Member/Policy Number:

    Secondary Group Number:

    Information of Policy Holder or Financially Responsible Party (If Not Self)

    Relationship to Patient:

    Policy Holder or Financially Responsible Party's Full Name:

    DOB: (MM/DD/YYYY)

    Phone Number:

    Address and Zip (if different):

    Referral Information

    How were you referred to us?

    Mental Health History

    Please detail your mental health history with diagnoses, current medications, previous medication trials, hospitalizations for mental health reasons, current or most recent treatment providers, and other details that would pertain to your treatment: (On your first appointment, please bring any records, lab results, testing and EKG/imaging that you may have.)

    Please detail your addiction history (drug, alcohol, gambling, sex, internet, etc.); any past treatment programs, current programs or providers; your longest period of sobriety; and your current relationship to your addiction: (Please bring any records that you may have to your appointment.)

    Please detail your family psychiatric history (depression, anxiety, bipolar, schizophrenia, addictions, suicide, etc.):

    Medical History

    Please detail your medical history with diagnoses, current medications, allergies to medications, current treatment providers, and other details that would pertain to your treatment: (Please bring your most recent medication list, labs, and EKG/imaging results, if you have them.)

    Please detail your family medical history:

    What is your reason for seeking care now?

    Office Policy Agreement

    All cancellations/reschedules made at least 2 days in advance of the scheduled appointment are not charged. Late cancellations/reschedules and no-show appointments will be charged according to the service at the self-pay rate. The no-show or late cancel/reschedule fee can be refunded in full for a 20 min appointment and at 50% for a 40 min appointment upon attendance of a make-up session within one week of the missed appointment. If the make-up session is dated outside the one week grace period, or if it is cancelled, no-showed, or rescheduled, then you will forfeit the refund. (If you cannot find an opening within one week, please call or email us.) Insurance will not be reimbursing you for this charge. For repeated no-shows or late cancel/reschedules, we reserve the right to charge.

    This practice requires each person to have active credit/debit card with sufficient funds on file in order to be an active patient/client. This card will be used primarily for no-show’s and late cancellations, copays for telemedicine appointments, and occasionally for outstanding charges due to extraordinary circumstances (this rarely happens and we will contact you prior to charging your card). You are aware that either the card(s) on file or another card used to make your appointment at Square.com may be charged for missed appointments or outstanding fees. By agreeing to the terms and providing your credit/debit card you are acknowledging that you are aware that your card will be charged according to office policies. After agreeing to the terms and providing your credit/debit card, if you contact your bank or card company to deny charges, resulting in a "charge back", any additional fees associated with that charge back will be added to the original fees. Thank you for your cooperation with this necessary policy. A complete set of office paperwork will be available for you to sign.

    I agree to MW Psychiatry's office policies and give permission to charge my card(s) accordingly.*