New Patients FormCurrently full and unable to schedule NEW patients. Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Address * Insurance Carrier * Select One Aetna Ambetter BCBS of Texas Cigna Compsych Humana Oscar Optum United Health Care Private Pay Insurance Member ID * Insurance Group ID * Reason for visit * Appointment Preference * Telemedicine In Person (Fridays only) Any current medical and psychiatric history including substance use disorder * Include inpatient psychiatric hospitalizations, substance abuse treatment centers, IOP, PHP, suicide attempts, or self injurious behaviors. Any current psychiatric care * Current or previous Psychiatrist and or therapist? Drug or Food Allergies * All current medications * Including over the counter, vitamins, and supplements Past psychotropic medications * Preferred Pharmacy * Including Address Referred by Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Relationship of Emergency Contact * Thank you!