New Patient Screening

New Patient Form

Complete this secure, HIPAA compliant form to determine insurance coverage before we schedule an appointment.
First Name*
Last Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Birth Sex*

MaleFemale
Email*
example@example.com
Phone Number*

Area CodePhone Number
Is it OK to leave a voicemail?

Yes, but no specific informationYes, and may leave specific health informationNo
Is it OK to leave a voicemail?*

Yes, but no specific informationYes, and may leave specific health informationNo
Is it OK to text you at this number?*

YesNo
Upload Drivers License or other Identification to verify your identity

Browse Files
Multiple files are allowed. May be: jpg, png, gif, bmp, doc, pdf. Cancelof
If you don't have your drivers license at the moment, you can email it at your convenience to inquiry@telepsychhealth.com Insurance companies, pharmacies, and federal law require us to verify your identity.
Insurance Information
Please upload your insurance information so we can check your benefits / coverage.
Upload front and back of insurance card

Browse Files
Multiple files are allowed Cancelof
Check box if you do not have insurance:

I do not have insurance and will pay out of pocket
If you don't have your insurance card at the moment, please email it as soon as possible to inquiry@telepsychhealth.com
If you are a dependent of another person for your insurance coverage, please fill in the primary member information:
Primary Insurance Member

First NameLast Name
Primary Member Date of Birth

MonthDayYear
Date
How did you hear about us?*
What is the most significant ISSUE for you?*
How can we help you?
Which of the following have you experienced in your lifetime? Check any that have had a significant impact or impairment on your life.

DepressionGrief/LossAnxietyAttention difficultiesTraumatic eventIrritabilitySleep problemsMemory problemsPanic attacksEating disorder
What psychiatric DIAGNOSES have you ever received?*
Which of the following TREATMENT OPTIONS are you interested in?

I want to see a therapist and start therapyI want to join group therapyI am considering prescription medicationsI am considering nonprescription medicationsAll of the above
Are you wanting certain MEDICATIONS prescribed? If so, which ones?*
If so, which ones?
Please note that we do NOT prescribe controlled substances such as Adderall, Ritalin, Xanax, Klonopin, Ativan
Please answer the next two questions considering the PAST MONTH...
Have you wished you were dead or wished you could go to sleep and not wake up?

YesNo
Have you actually had any thoughts of killing yourself?

YesNo
Have you been thinking about how you might do this?

YesNo
Have you had these thoughts and had some intention of acting on them?

YesNo
Have you started to work out the details of how to kill yourself? Do you intend to carry out this plan?

YesNo
Have you EVER done anything, started to do anything or prepared to do anything to end your life?

YesNo
CSSRS Score
TelepsychHealth collaborates with Headlamp Health which allows us to gather your historical medical records, track your mood and behaviors, and build your awareness of how these feelings may contribute to your overall health and wellbeing. You will then be able to access this record from Headlamp Health. If you would like to learn more: https://www.headlamp.com/patients.

Do you want to give permission to Headlamp Health to obtain your historical medical records?
I'd like to give permission to Headlamp Health to pull my records.*

Yes I give permissionNo I do not give permission
Once you have registered to be a new patient in our practice, you will get a text message from Dr. Bruce Bassi at Headlamp Health to invite you to download the app.
Do you need any paperwork completed, such as disability or work release?*

YesNo
What paperwork?*
Please note, a disability evaluation is a specific type of evaluation that we do not perform due to practice restrictions. If you are receiving any money through workers' compensation, you cannot be seen in our practice. By submitting this form, you attest that you are not receiving any money through workers' compensation.
Would you like to be added to our WAITLIST for an earlier appointment?

YesNo
Would you consider a 30 min slot, if one were to open? We often have many more 30 min appt cancellations.

YesNo
Should be Empty:

New Patient Form

Insurance Information