NCHH Online Registration Form

Patient's Email *
example@example.com
DateTime
Patient's Full Name *

First Name Last Name
Patient's Preferred Name *
Patient's Address *

Street Address

Street Address Line 2

City State

Zip Code
Patient's Date of Birth (we see ages 14 and up only) *

Month Day Year
Can we use the patient email to communicate with you, the patient (including email reminders)? *

YES NO
Patient or Parent/Guardian's Mobile Number *

Area Code Phone Number
Can we use your Mobile Number to communicate with you (including text reminders and text communication)? *

YES NO

Step 1: Complete Questionnaire
Who is the patient's emergency contact? *
What relationship is the emergency contact to the patient? *
What is the emergency contact's phone number? *
If you were referred, tell us the name of who referred you? *
Type OTHER if you answered above
Is the patient under 18 years of age? *

YES NO
Does the patient have a legal guardian or a custodian parent? *

YES NO NOT APPLICABLE
Who is the custodial parent?

Prefix First Name Middle Name Last Name Suffix
Can we contact the other parent?

YES NO NOT APPLICABLE
Contact information for the other parent (Full name and phone number)?
Write NONE if not applicable

This section is for patients who are under 18 years of age or who have a legal guardian. Write NONE if it doesn't apply to patient.
The Custodial Parent or Legal Guardian should REVIEW AND SIGN this Consent to Treat Minor IF Patient is under 18 years of age or has a legal guardian.

If the patient is under the age of eighteen or unable to consent to treatment, a legal custodian of the Patient will be required to authorize and consent for the initial evaluation and on-going treatment on behalf of the Patient.

I voluntarily consent that my child, or ward, will participate in a mental health evaluation (e.g. psychological or psychiatric) and/or treatment by staff from the NeuroScience and TMS Treatment Center. The evaluation and treatment will be made by a licensed mental health clinician (a psychotherapist, psychologist, psychiatric nurse practitioner, psychiatrist, or licensed therapist). I understand that following the evaluation and/or treatment, complete and accurate information may be provided concerning each of the following areas:

1. The benefits of the proposed treatment
2. Alternative treatment modes and services
3. The manner in which treatment will be administered
4. Expected side effects from the treatment and/or the risks of side effects from medications (when applicable).
5. Probable consequences of not receiving treatment
6. Expectations regarding the length and frequency of treatment

It may be beneficial to my child, or ward, as well as the referring professional, to understand the nature and cause of any difficulties affecting my child’s, or ward’s, daily functioning, so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. As a parent or guardian of the patient seeking evaluation and treatment, I may have useful information for the professionals doing the evaluation and ongoing treatment, because of this fact, please disclose all information which can be helpful to the treatment team at any point in the care process. Information can be given verbally, or in written communication.

Treatment will hopefully give benefits, which may include improved cognitive or academic performance, emotional and physical health status, quality of life, and awareness of strengths and limitations.

Fees are based on the length or type of the evaluation or treatment, which are determined by the nature of the service. As the parent or guardian of the patient, I will be responsible for charges. Fees are available to me upon request and may be referenced in the new patient packet.

Information from my child’s, or ward’s, evaluation and/or treatment is contained in a confidential medical record at the NeuroScience and TMS Treatment Center, and I consent to its use by staff for the purpose of continuity of my child’s, or ward’s, care. Per Tennessee mental health law, the information provided will be kept confidential with the following exceptions: 1) if my child, or ward, is deemed to present a danger to himself/herself or others; 2) if concerns about possible abuse or neglect arise, or 3) if a court order is issued to obtain records.

I have the right to withdraw my consent for evaluation and/or treatment of my child, or my ward at any time by providing a written request to the treating clinician. I have read and understood the above, have had an opportunity to ask questions about this information, and I consent to the evaluation and treatment of my child or my ward. I also attest that I am the legal guardian and have the right to consent for the treatment of this child or ward. I understand that I have the right to ask questions of my child’s, or my ward’s service Clinician about the above information at any time.
Full Name of adult signing as the custodial parent or legal guardian

First Name Last Name
Signature of Custodial Parent or Legal Guardian

Clear

Tell us some information about you (the patient)
Why do you want to be a patient in our clinic? What concern has caused you, the patient, to seek help in our clinic? *

0/250
What are your goals and how do you think we can help? *
What do you, the patient, do with most of your days? If you are employed, tell us who employs you. *
Are you (or the patient) taking any medications or other substances for your symptoms? Which ones? (please list all medications, supplements, over the counter or otherwise) - If none, say "NONE" *

0/500
Are you seeing a therapist now? Have you seen a therapist in the past? Have you see a psychiatrist in the past? *

0/500
Have you (or the patient) been hospitalized for symptoms? When and where? *

0/250

STEP 2: Complete the Insurance Section
We are out of network with insurance at NCHH.

If you would like us to submit your claim to insurance when you see other clinicians in the office, we will need information about your policy. If you are privately paying for the appointment (not filing insurance) or using insurance which we are not in-network clinicians, then you do NOT need to fill out this section, and can write NA or NONE in the sections below.

Dr. Cochran does not see in-network patients in this clinic.
Would you like us to file for out of netwok benefits? (for example, if you have out of network benefits, your insurance may pay for part of your care in this clinic) *

YES NO
What is the Name of the Subscriber (who's name is on the insurance policy, if not the patient)?
Write the word NONE, if you are privately paying for the charges
What is the Date of Birth of the Subscriber?
If we are not filing insurance, write 00/00/0000
Give us the Insurance Subscriber's Address (if the same as the patient's address, just write "same as patient's address above"). If private paying, write "NONE"
The Insured Subscriber's POLICY ID Number?
Write None if private paying
The Insured Subscriber's Group ID Number?
Write None if private paying
What relation is the Subscriber to the patient?
Write-in Myself/ Parent/ Spouse/ Guardian/ or other
Please send a copy of your insurance card (FRONT & BACK) & driver's license with this form if you want us to file for out-of-network benefits

If you lack the technology to do this, please email support@healnashville.com or call 615-379-8600, and we can discuss other ways you could send or drop off your information.
UPLOAD the FRONT of the Patient's Insurance Card

Browse Files

Cancel of
UPLOAD the BACK of the Patient's Insurance Card

Browse Files

Cancel of
UPLOAD a copy of the patient's or responsible parties drivers license

Browse Files

Cancel of

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please read the following letter about our clinic and then, begin the application

Step 1: Complete Questionnaire

This section is for patients who are under 18 years of age or who have a legal guardian. Write NONE if it doesn't apply to patient.

Tell us some information about you (the patient)

STEP 2: Complete the Insurance Section

Please send a copy of your insurance card (FRONT & BACK) & driver's license with this form if you want us to file for out-of-network benefits

STEP 3: Review & Agree to Office Policies on our website, www.healnashville.com and complete the Signatures, Service Selection & Submission

Service(s) Selection

Read ALL NCHH policies: Privacy, General Office, and Insurance & Payment Policies. These policies can be found on our website, www.hopeforyourbrain.com.