Advance Behavioral Health Services

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New Patient Request Appointment Form

If this is an emergency please call 911. Please enter the information on the form below and our intake department will contact you within 1 business day.

    What is the reason for the appointment?

    Patient's Full Name*

    I am the patient*

    Gender at Birth*

    Gender Identity (Optional)

    Patient's Preferred Language:

    Phone Number*

    Area code

    Phone

    Date of Birth*

    Address

    Street Address

    Street Address line-2

    City

    State / Province

    Postal / Zip Code

    Country

    E-mail Address*

    Insurance*

    Insurance Cardholder Name

    Insurance Card ID Number

    Insurance Card Group Number

    When is your preferred time for us to call you to schedule the
    appointment? (i.e. 8am-10am, 4pm-6pm etc)*

    Have you previously attended our facility*

    Has the person seeking treatment ever been treated for mental health
    diagnosis in the past? If so, what was the diagnosis, who was/is the provider and when?

    Is the patient currently taking any psychiatric prescription
    medications? If so, any injectible medications?

    Has the patient recently been hospitalized in a psychiatric hospital? If
    yes, when?

    Does the person seeking treatment have a pending court or legal case, custody evaluation, or wanting a one time evaluation? If yes, please explain.

    Has the person seeking treatment received substance abuse treatment, Suboxone, or is currently abusing substances? If yes, please explain.

    How did you hear about us?


    Please verify that you are human*