Medication Management-Adult

Client Information

First Name *

Last Name *

Date of birth *

Phone Number *

Email Address *

Address

Postal code *

How would you like to receive services? *

In-person Only

Telehealth Only

Open to Both

Insurance Information

Primary Insurance Provider *

Primary Subscriber *

Self

Spouse

Parent

Primary Subscriber’s Name *

Primary Subscriber’s Date of Birth *

Primary Insurance Member ID *

Upload Insurance Card Option

Secondary Insurance (Optional)

Secondary Insurance Provider

Secondary Insurance Member ID

Upload front and back of insurance card

Referral Source

How did you hear about us? *

If Other, how did you hear about us?

Scheduling Preferences

Preferred Appointment Time

Best Way to Contact You

Additional Information

Is there anything else you would like us to know?

Email Risk Acknowledgment
I understand that the use of email and SMS text messages is inherently

insecure and poses a risk to the security and confidentiality of my protected

health information. I consent to therapists, providers, and/or office staff

communicating with me via email or text message.