Appointments

Location
Choose an OMH office location:*
How were you referred to our East Boulder, CO office?*
Please tell us how you were referred to our East Boulder, CO office*
How were you referred to our Fort Collins, CO office?*
Please tell us how you were referred to our Fort Collins, CO office*
How were you referred to our Back Bay, MA office?*
Please tell us how you were referred to our Back Bay, MA office*
How were you referred to our Coolidge Corner, MA office?*
Please tell us how you were referred to our Coolidge Corner, MA office*
What is the full name of the provider who referred you to OMH?*

Personal Information
First name:*
Last name:*
Date of birth (MM/DD/YYYY):*
Date Format: MM slash DD slash YYYY
Email address:*
Legal sex:*
We 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.
Main phone:*
Choose identification type:*
Enter ID number of chosen ID type:*

Your Address
Street address:*
Street Address
Apartment:
Address Line 2
City:*
City
State:*
State
Zip code:*
ZIP Code

Employment status:*
I need help with:*
Preferred services:*
Please say more about how we can help you:*
Are you interested in receiving OMH services online?*
For this option, you will need to have a reliable internet or cellular connection, a laptop or mobile device with a camera and microphone, and a quiet location to meet with your provider for the length of your appointment.
Which therapy group would you like to join?*
Information and Consent*
The chronic pain support group at OMH is sponsored by Boulder Community Health (BCH), and is free of charge to all participants 18 yrs of age or older who live in Boulder County. To attend this group free of charge, please provide consent to share your provided information and responses with BCH.
Seating Specifications for Group*
The chronic pain support group requires sitting in a standard office chair for the duration of each session. Participants are allowed to freely move around or take breaks as needed. Are you able to meet this requirement?
Financial Disclosure for Group*
This group is offered free of charge to Boulder county residents through a generous gift of the Health Equity Fund. Please select the answer that describes your total yearly household gross income. Your answer does not change your eligibility to participate in this group.
Household Members Disclosure for Group*
This group is offered free of charge to Boulder county residents through a generous gift of the Health Equity Fund. Please select the answer that describes the total number of member in your household. Your answer does not change your eligibility to participate in this group.

Current medications you take and their doses:
Allergies:
Have you ever been hospitalized for any psychiatric reason?*
Please describe circumstances of psychiatric hospitalization(s):
Have you ever experienced suicidal thoughts or actions?*
Have you experienced suicidal thoughts or actions in the last 3 months?*
Please elaborate on the frequency and intensity of these thoughts or actions:
Have you ever engaged in self harm behaviors (like cutting, burning, etc?)*
Please briefly describe the nature and impact of these behaviors:
Do you have a history of alcohol or substance abuse?*
Please briefly describe your history of alcohol or substance abuse:
Are you currently misusing alcohol or substances?*
Briefly elaborate on type and frequency of current alcohol or substance use:
Urgency of your request:*
Choice of payment:*

Name of your insurance plan, and type of coverage:*
For example, Blue Cross of Texas, PPO.
Insurance plan ID number:*
We require this information to confirm your behavioral health coverage for our services.
Primary account holder information:*
Full name of account holder:*
First
Account holder's date of birth (MM/DD/YYYY):*
Date Format: MM slash DD slash YYYY
Account holder's street address:*
Street Address
Account holder's apartment number:
Address Line 2
Account holder's city:*
City
Account holder's state:*
State
Account holder's zip code:*
ZIP Code
Account holder's main phone:*
Account holder is my:*
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