Patient Registration Form

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 Name Middle Initial Last Name

Parent / Guardian Name (if patient is a minor)

First Name Last Name

Today's Date *

Status *

New patient, requesting an appointment Returning patient after more than 12 months New insurance plan New patient, has already made an appointment Other: Please Describe

Clinician(s) Preference

John Dwyer, PhD Licensed Clinical Psychologist Melissa Findlay, LCSW Licensed Clinical Social Worker David Epstein, PsyD Licensed Clinical Psychologist Elizabeth Novak, LCSW Licensed Clinical Social Worker Jill Sexton-Newton, LPC Licensed Professional Counselor Julianne Luck, MSW, Supervisee in Social Work Unsure or No Preference

Patient Age *

Patient Date of Birth *

Month Day Year

Gender *

Male Female Other (please describe)

Email *

Adult patient or parent/guardian

Primary Phone Number *

Adult patient or parent/guardian

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Patient Marital Status *

Single Partnered Married Divorced Other

Employment/School *

Working Working and Attending School Attending School None Other: 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). *

Yes No I do not have a PCP Will 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 ? *

No Yes

If yes, please list providers and date range of treatment.

Are you or your child currently taking psychiatric medication(s)? *

No Yes

If yes, please list names of medications, the prescriber(s), and how long medication have been taken.

Primary Insurance Name *

If not insured or wish to not use insurance type "self pay"

Primary Insurance Member/Subscriber Number *

Type "None" if self-pay

Primary Insurance Group Number

Who is the primary insurance subscriber *

Patient Mother Father Spouse Other

If the patient is not the subscriber, the subscriber's name and 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 Member/Subscriber Number

Secondary Insurance Group Number

Who is the secondary insurance subscriber

Patient Mother Father Spouse Other

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.

No Yes: Please Describe:

Please review the following documents:

HIPAA Privacy Practices and Policies

Office Policies and Procedures

Telemedicine services (if used)

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 Name Middle Initial Last 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).

Patient Registration Form

Primary Health Information