New Patient Information Form
Thank you for your interest in scheduling an appointment at Center for Behavioral Health & Sleep Disorders! Please take a few moments to fill out our new patient information form. We will reach out to you in a few business days with more details.
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Full name: *
Date of Birth: *
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DD
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Phone Number (preferably cell): *
Address: *
Email: *
Primary Insurance: *
Please include name of insurance company, policy number, and group number (if applicable). If self-pay, please type 'self-pay'.
Secondary Insurance:
Please include name of insurance company, policy number, and group number (if applicable). If self-pay, please type 'self-pay'.
Referring Physician/Provider:
What is your reason for requesting an appointment? *
Current length of depressive episode
In current episode of depression, what medications were tried? 
Please list any side effects to medications, what did not work, etc. 
Have you undergone psychotherapy?
Please list current psychiatric medications you are taking (including controlled medications): *
Current drug use or alcohol use? *
If you answered 'yes' to the above question, please specify:
Current Marijuana use? *
If you are below the age of 18, please specify the name of a parent or legal guardian.
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