PATIENT INTAKE/REFERRAL INFORMATION

PATIENT INTAKE/REFERRAL INFORMATION

Thank you for choosing CMPS for your behavioral healthcare needs. We look forward to working with you. Please submit the following information, and we will be in touch with you within 24 business hours.
Please choose Office Location *
PATIENT INFORMATION
Patient Legal Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender *

Male Female
Insured/Parent/Guardian Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender *

Male Female
Cell Phone Number *
Please enter a valid phone number.
Other Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Who Referred
Please Check One

Doctor Friend Coworker Other
Other
Primary Insurance Company *
Primary Insurance ID *
Phone Number on Card (If Available)
Please enter a valid phone number.
Primary Insurance Company
Primary Insurance ID *
Phone Number on Card (If Available)
Please enter a valid phone number.
Services Requested (Check All That Apply)

Psychiatry (medication management) Counseling/Therapy Psychological or Neuropsychological Testing Transcranial Magnetic Stimulation (TMS) I’m not sure
BRIEF CLINICAL INFORMATION (Symptoms, Current Issues)
Reason for Seeking Services
IF YOU ARE IN CRISIS and need immediate emergency attention, PLEASE CALL 911 or go to your local hospital emergency room. This intake form will not direct you to a crisis line or crisis services. It may be several hours or the next day before we can respond, verify benefits, and schedule an appointment.

In order to schedule and hold an appointment, we require a credit card. Please provide credit card information only when requested by phone.
(After we enter the card information, according to federal law, the actual number cannot be seen))

We DO accept the following insurance companies:
Medicare, Blue Cross Blue Shield, Aetna, CIGNA, United Healthcare/OPTUM.

We DO NOT accept the following insurance companies:
Medicaid, Beacon, Freedom, Value Options, Magellan, Great West, Mental Health Network
Should be Empty:

PATIENT INTAKE/REFERRAL INFORMATION

PATIENT INFORMATION

BRIEF CLINICAL INFORMATION (Symptoms, Current Issues)