Patient Registration Form

Patient Registration Form

Please Complete
If you have never been seen at the Meridian Group before, have not been here for more than 12 months, or have changed insurance plans, please complete this form to request a first appointment. If you do not already have an appointment, you will be contacted by email or telephone within two business days to let you know what is available. All information is confidential. If you have any questions, call our office at 804-751-8644.
Patient Name*

First NameMiddle InitialLast Name
Parent / Guardian Name (if patient is a minor)

First NameLast Name
Today's Date*
Status*

New patient, requesting an appointmentReturning patient after more than 12 monthsNew insurance planNew patient, has already made an appointmentOther: Please Describe
Clinician(s) Preference

John Dwyer, PhD Licensed Clinical PsychologistMelissa Findlay, LCSW Licensed Clinical Social WorkerDavid Epstein, PsyD Licensed Clinical PsychologistElizabeth Novak, LCSW Licensed Clinical Social WorkerJill Sexton-Newton, LPC Licensed Professional CounselorJulianne Luck, MSW, Supervisee in Social WorkLeah Harlan, MA, Resident in CounselingChelsi Simmons, LPC Licensed Professional CounselorUnsure or no preference
Patient Age*
Patient Date of Birth*

MonthDayYear
Gender*

MaleFemaleOther (please describe)
Email*
Adult patient or parent/guardian
Primary Phone Number*
Adult patient or parent/guardian
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Marital Status*

SinglePartneredMarriedDivorcedOther
Employment/School*

WorkingWorking and Attending SchoolAttending SchoolNoneOther: Please Describe
Who referred you to our office?*
Primary Care Provider*
Type "none" if you do not have a PCP
May we contact your PCP after your first visit (as needed).*

YesNoI do not have a PCPWill decide later
Please briefly describe the reason you are seeking services. *
You will have an opportunity to provide more detail after you have made an appointment with one of our clinicians on the Adult or Child/Adolescent Form
Are you (or child for child patients) currently or in the past been in treatment with an other mental health provider and/or psychiatrist or ?*

NoYes
If yes, please list providers and date range of treatment.
Are you or your child currently taking psychiatric medication(s)?*

NoYes
If yes, please list names of medications, the prescriber(s), and how long medication have been taken.
Primary Health Information
Employee Assistance Program (EAP)

Please complete the following questions if you would like to use EAP benefits (otherwise leave blank). Please note that Compsych EAP is not accepted by any provider and our Psychologists do not accept EAP benefits. Some providers accept EAP, please call our office manager at 804-751-8644 ext 110 to confirm whether your requested provider accepts EAP.
EAP Provider Name
Authorization #
# of sessions authorized:
Insurance information
Primary Insurance Name*
If not insured or wish to not use insurance type "self pay"
Primary Insurance Subscriber or Member ID*
Type "None" if self-pay
Primary Insurance Group Number*
Type "None" if self-pay
Primary Insurance Subscriber Name*
Type "None" if self-pay
Who is the primary insurance subscriber*

PatientMotherFatherSpouseOther
If the patient is not the subscriber, the subscriber's date of birth.
Aetna for HCA employees requires SSN for billing.
For patients with Aetna HCA only, please provide subscriber social security number
Aetna for HCA employees requires SSN for billing.
Secondary Insurance Name
Leave blank if there is no secondary insurance
Secondary Insurance Subscriber or Member ID
Secondary Insurance Group ID
Secondary Insurance Subscriber Name
Who is the secondary insurance subscriber

PatientMotherFatherSpouseOther
If the patient is not the subscriber, the subscriber's date of birth.
Aetna for HCA employees requires SSN for billing.
Photo of the front of your insurance card. (if unable to do leave blank)
Photo of the back of your insurance card. (if unable to do leave blank)
Check if you or your child receives disability benefits.

NoYes: Please Describe:
Please review the following documents:
I have reviewed the HIPAA Privacy Practices and Policies and the Office Policies and Procedures below. I agree to treatment for myself or my child. If using insurance, I also agree that insurance may be billed and payment made to The Meridian Group and / or specific clinician seen for services rendered*

Yes
Your Signature (use mouse, finger tap, or digital pen)

Clear
Who will be responsible for payment of this account? Please note you may not sign for someone else. This is typically the patient or the parent/guardian who brings the patient for treatment.*

First NameMiddle InitialLast Name
Your Name (if different from responsible party above).
Thank you for completing this form. If you already have an appointment, please also complete the Adult Intake Questionnaire (for adults) or Child and Adolescent Intake Questionnaire (parent or guardian for minors 17 years old and younger).
Should be Empty:

Patient Registration Form

Primary Health Information

Employee Assistance Program (EAP)

Insurance information