New Patient Therapy Appointment Request Form
*Please note that this form is not a guaranteed appointment.

This form is the initial step to our intake process. Please fill out every question presented, as any incomplete answer may delay the intake process.

This form does not guarantee an appointment. This form intends to request an evaluation and determine whether we are the best fit for the patient.

*If you or someone you know is in an emergency crisis, dial 512-472-4357, or 911.*
Veterans Suicide Hotline: 1-800-986-1891
National Suicide Prevention Lifeline: 1-800-273-8255
Sign in to Google to save your progress. Learn more
Email *
New patient's full name (Please include preferred pronouns) *
Phone number (xxx) xxx-xxxx *
May we leave a voicemail? *
Date of birth (00/00/0000) *
Parent/Guardian (if patient is a minor) *
Who does the patient live with?
Custody/Legal issues (ex: divorce, etc.)
Why are you seeking therapy at this time?
Problems/Concerns *
Please note our clinician is accepting BCBS insurance and self pay until further notice
Clear selection
BCBS user ID
BCBS group #
BCBS primary subscriber and DOB
Is the family/client open to collaborative care with their school and/or physicians? (within or outside of our clinic)
Clear selection
Thank you
We appreciate your interest and time. Our intake specialist will contact you upon review.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Austin Family Psychiatry. Report Abuse