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 NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Insured/Parent/Guardian Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload the Front and Back of Your Insurance Card

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Who Referred
Please Check One

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

Psychiatry (medication management)Counseling/TherapyPsychological or Neuropsychological TestingTranscranial Magnetic Stimulation (TMS)I’m not sure
BRIEF CLINICAL INFORMATION (Symptoms, Current Issues)
Reason for Seeking Services*
Briefly explain why you are seeking services at this time?*
Are you in crisis or suicidal?*

YesNo
if you answer yes, call 911, 211 or go to your local ER.
If applicable, do you have a history of mental health issues? If so, do you know what diagnoses have been provided?
If applicable, how many inpatient psychiatric hospitalizations have you ever experienced? What is the date of the last admission?
How often do you drink alcohol or use other substances (what other substances do you use)? Do you have a history of alcohol or other substance abuse?*
What medications are you prescribed?*
Is there any legal or court involvement?
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
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PATIENT INTAKE/REFERRAL INFORMATION

PATIENT INFORMATION

BRIEF CLINICAL INFORMATION (Symptoms, Current Issues)