New Patient Enrollment Form

Medical History
Primary Reason for Visit:
EX: Depression, Anxiety, Sleep, Trouble concentrating...
PRIMARY CARE PHYSICIAN

NAMEPHONE NUMBER
Height blanksWeight   pounds

Are you currently taking any medications?   Yes   No

Are you currently in counseling or therapy? Yes   No

Have you ever been admitted to inpatient for mental health or substance abuse? If so when and where:
Date
Date
Date
Please list your current medication and dosage.
Include Vitamins and Supplements

How did you hear about Aware Behavioral Health?*
What is your preferred pharmacy? *
(Name and Address)
Financial Policy and Consent to Treatment:
We are in network with BCBS and UHC; please make sure you have included your insurance informationa and that we have verified coverage. You may have a copay, coinsurance, or allowable due based on your coverage and this is due at time of service (or before).

Self pay rates are $300 for initial consultation and follow ups are $150. Payments can be submitted via the payment portal on our website or by calling the office. Please provide 24 hour notice for all cancellations and reschedules. We understand things do come up, but please email, text, or call the office as soon as possible so that we can offer your time to someone else. There is a $50 no show/late cancel fee.

I hereby consent to evaluation, testing, and treatment as directed by my Aware Behavioral health physician or his or her designee.
Signature

Clear
Please take a picture of your driver's license, passport, or ID:
Should be Empty:

New Patient Registration