Appointments Request an appointment today! This form is HIPAA compliant and secure. "*" indicates required fields Step 1 of 6 16% Location InformationChoose an OMH office location:*CO: Denver CentralCO: East BoulderCO: Fort CollinsMA: Back BayMA: Coolidge CornerMT: BillingsHow were you referred to us?*My primary care doctor or nurse practitionerMy health insurance websiteMy psychiatrist or psychiatric nurse practitionerMy psychotherapy counselorOnline search engineOnline mental health provider directoryOtherWhat is the name of your psychiatrist or psychiatric nurse practitioner?* What is the name of psychotherapy counselor?* What is the name of the directory you found us in?* How were you referred to us?* Do you have a primary care provider?*YesNoWhat is the name of your primary care provider?* Identification InformationFirst name:* Last name:* Date of birth (MM/DD/YYYY):* MM slash DD slash YYYY Legal sex:*MaleFemaleWe ask for this information as it helps us to communicate with your insurer, and to register your account with us. To tell us more about your gender identity or provide other information on how we can best address you, please complete the optional field that follows. Elaborate on how you prefer to be addressed (optional): Add any information you wish to share regarding your gender identity, preferred pronouns, or preferred nicknames here. This information will not be shared outside of OMH. Our entire team is committed to making everyone feel safe, welcome, and respected. Choose identification type:*Social Security NumberDriver's License NumberPassport NumberEnter ID number of chosen ID type:* Contact InformationYour street address:* Street Address Apartment: Address Line 2 City:* City State:* AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip code:* ZIP Code Your preferred email:* Your preferred phone:* Personal Information and GoalsHow would you like to receive our services:*I would prefer meeting online onlyI do not have a preference on how I meet with my providerI would prefer meeting in person onlyEmployment status:*Working Full TimeWorking Part TimeUnemployed seeking workUnemployed not seeking workHomemakerRetiredRelationship status:*MarriedNot marriedStudent status:*Full time studentPart time studentNot a studentI need help with:* Anxiety or nervousness Depression or mood Insomnia or sleep problems Relationships or friendships Attention or focus Substance misuse Other Prefer not say Preferred service(s) type:* Medication management TMS Adult counseling College counseling Insomnia treatment Psychological testing services Trauma counseling Couples counseling Teen counseling Child and family counseling Group therapy Please say more about how we can help you:* Mental Health Care HistoryCurrent medications you take and their doses:* Allergies:* Section BreakHave you ever been hospitalized for any mental health reason?*YesNoPlease describe circumstances of your hospitalization(s):* Section BreakHave you ever experienced suicidal thoughts or actions?*YesNoHave you experienced suicidal thoughts or actions in the last 3 months?*YesNoPlease elaborate on the frequency and intensity of these thoughts or actions:* Section BreakHave you ever engaged in self harm behaviors (like cutting, burning, etc?)*YesNoPlease briefly describe the nature and frequency of these behaviors:* Section BreakHave you ever misused alcohol or any other substances?*YesNoAre you currently misusing alcohol or substances?*YesNoPlease briefly describe your current or past history of alcohol or substance misuse:* Section BreakUrgency of your appointment request:*Prefer appointment within 1 weekPrefer appointment within 2 weeksPrefer appointment within 4 weeksVery urgent request for appointment Fees and InsuranceChoice of payment:*Private InsuranceMedicareMedicaidSelf-payWho is the responsible party for your health insurance plan(s):*I am the responsible party for my health planI am dependent on a health plan that someone else is responsible forName of your primary insurance plan, and type of coverage:* For example, Blue Cross of Texas, PPO.Primary insurance plan ID number:* We require this information to confirm your behavioral health coverage. Do you have any secondary or supplemental insurance?*YesNoName of your secondary insurance plan, and type of coverage:* For example, AARP Medicare supplemental insuranceSecondary insurance plan ID number:* We require this information to confirm your behavioral health coverage.In addition to having your own health insurance, are you currently listed as a dependent on anyone else’s health plan?*YesNoSometimes, patients under the age of 26 can still be listed on parent's insurance plan, in addition to a plan from work or school. Please confirm that you do not have any insurance benefits under any other plan.First name of person who holds the health plan:* First Last name of person who holds the health plan:* Last Date of birth of health plan holder (MM/DD/YYYY):* MM slash DD slash YYYY Health plan holder's relationship to you:*SpouseMotherFatherOtherStreet address of health plan holder:* Street Address Apartment of health plan holder: Address Line 2 City of health plan holder:* City State of health plan holder:* AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip code of health plan holder:* ZIP Code Preferred email of health plan holder:* Preferred phone of health plan holder:*Name of plan holder's primary insurance plan, and type of coverage:* For example, Blue Cross of Texas, PPO.Primary insurance plan ID number:* We require this information to confirm your behavioral health coverage. Does the plan holder have any secondary or supplemental insurance?*YesNoName of plan holder's secondary insurance plan, and type of coverage:* For example, AARP Medicare supplemental insuranceSecondary insurance plan ID number:* We require this information to confirm your behavioral health coverage.CAPTCHA