Intake form

NEW PATIENT FORM


Thank you for your interest in Relief Mental Health! If you are interested in any of our services, please complete and submit the following form, and a member of our intake team will reach out to you within 24 business hours to schedule an initial consultation, as long as your care falls within our scope of practice. While our expertise is broad, there are certain mental health diagnoses that fall outside our scope of practice. We cannot guarantee patients will be scheduled for services after completing and submitting this form, nor will initial consultations guarantee a continued patient-provider relationship.

We appreciate your trust in us and value the opportunity to support you on your mental health journey and help you find relief.

 

PATIENT CONTACT INFORMATION


PRIMARY INSURANCE INFORMATION


SECONDARY INSURANCE INFORMATION


PATIENT INTAKE


We cannot guarantee that our providers will sign off on any disability or FMLA paperwork; it will be at the discretion of the treating provider.

If requesting therapy services: Please provide your preferences and availability below.

MEDICATION HISTORY


Please list your current psychiatric medications, as well as any past psychiatric medication trials with approximate dosages, dates of use, and the reason for discontinuation, if applicable.