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
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Email *
New patient's full name (Please include preferred pronouns) *
Phone number (xxx) xxx-xxxx *
By checking "Yes I Agree", I consent to receive SMS from Austin Family Psychiatry. Reply STOP to opt-out; Reply HELP for support or visit our website; Message & data rates may apply; Messaging frequency may vary. Visit our website to see our privacy policy and our Terms of Service.
May we leave a voicemail? *
Date of birth (00/00/0000) *
MM
/
DD
/
YYYY
Parent/Guardian (if patient is a minor) *
Who does the patient live with?
Custody/Legal issues (ex: divorce, etc.)
Problems/Concerns *
Required
Insurance
Clear selection
Insurance Member ID
Insurance Group Number
Primary Subscriber's Name and Date of Birth
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.
Submit
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