Wellness Pre-Assessment &#8211; Ethos Behavioral Health

New Patient Inquiry Form - Yoga Therapy

Hello and welcome to Ethos Wellness! Prior to scheduling yoga therapy services, we need to collect some background information to verify that we're able to work together. We will reach out to you with next steps upon completion of this form. Please feel free to email rivernorth@ethosbhg.com if you have any questions for us, and thank you for taking the time to complete this brief survey.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Identification Card*

Browse Files
Please attach a photo of the front of your identification card (e.g. driver's license, passport, state ID). Cancelof
How did you hear about Ethos?*
e.g. Psychology Today, another provider, etc.
Brief Description of Presenting Problem*
What brings you to Ethos?
Brief Description of Interest in Yoga Therapy*
What do you hope to gain from participating in yoga therapy services?
Are you currently engaged in other types of therapy services?*

YesNoOther
Preferred Appointment Days

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Preferred Appointment Times

6 am - 9 am9 am -12 pm12 pm - 3 pm3 pm - 6 pm6 pm - 9 pm
By accepting the terms and conditions, I authorize the use and disclosure of the protected health information described in the form, subject to the additional precautions under the federal and state laws as applied to disclosure of Mental Health Records. Furthermore, I consent to fully understanding that any information relayed to me about my benefit is not a guarantee of benefits, but our best estimate given the information shared by your insurance company. I also understand that information used or disclosed may be subject to re-disclosure by the recipient and may no longer be protected by federal HIPAA privacy regulations
Click this box to accept the terms and conditions*

Click this box to accept the terms and conditions
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Patient Inquiry Form - Yoga Therapy