Appointments Request an appointment today! This form is HIPAA compliant and secure. Step 1 of 6 16% LocationChoose an OMH office location:*CO: East BoulderCO: Fort CollinsMA: Back BayMA: Coolidge CornerHow were you referred to our East Boulder, CO office?*Aetna Provider DirectoryCigna Provider DirectoryAnthem Blue Cross Blue Shield Provider DirectoryGoogle / Online SearchPsychology TodayUC HealthSCL HealthBoulder Community HealthCentura Health Physician GroupCU Boulder Counseling and Psychiatric ServicesCU Boulder Wardenburg Health ServiceCrossroads Medical CenterBoulder Valley Family PracticeFlatiron Internal MedicineBroomfield Family PracticeBoulder Medical CenterOtherPlease tell us how you were referred to our East Boulder, CO office* How were you referred to our Fort Collins, CO office?*Aetna Provider DirectoryCigna Provider DirectoryAnthem Blue Cross Blue Shield Provider DirectoryGoogle / Online SearchPsychology TodayUC HealthSCL HealthCSU Behavioral Health ServicesOtherPlease tell us how you were referred to our Fort Collins, CO office* How were you referred to our Back Bay, MA office?*Blue Cross Blue Shield of MA Provider DirectoryGoogle / Online SearchPsychology TodayHarvard Vanguard Medical AssociatesBrigham and Women's Primary Care AssociatesSchool Counseling Center, Boston UniversitySchool Counseling Center, Harvard UniversitySchool Counseling Center, Northeastern UniversitySchool Counseling Center, Other SchoolOtherPlease tell us how you were referred to our Back Bay, MA office* How were you referred to our Coolidge Corner, MA office?*Blue Cross Blue Shield of MA Provider DirectoryGoogle / Online SearchPsychology TodayHarvard Vanguard Medical AssociatesBrigham and Women's Primary Care AssociatesSchool Counseling Center, Boston UniversitySchool Counseling Center, Harvard UniversitySchool Counseling Center, Northeastern UniversitySchool Counseling Center, Other SchoolOtherPlease 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 InformationFirst name:* Last name:* Date of birth (MM/DD/YYYY):* MM slash DD slash YYYY Email address:* 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. Main phone:*Choose identification type:*Social Security NumberDriver's License NumberPassport NumberEnter ID number of chosen ID type:* Your AddressStreet address:* Street Address Apartment: Address Line 2 City:* City State:* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip code:* ZIP Code Employment status:*Working Full TimeWorking Part TimeFull Time StudentPart Time StudentRetiredHomemakerUnemployed Seeking WorkUnemployed Not SeekingI need help with:*AnxietyDepressionRelationshipsAttention or FocusSubstance MisuseOtherPrefer Not To SayPreferred services:*Medication ManagementIndividual CounselingMedication Management and Individual CounselingInsomnia TreatmentGroup PsychotherapyPsychological TestingCouples CounselingFamily CounselingTeen Counseling for my Son or DaughterChild Counseling for my Son or DaughterChild and Family InvestigationParental Responsibility EvaluationOtherNot Sure At This TimePlease say more about how we can help you:* Are you interested in receiving OMH services online?*Yes, I would prefer to meet with my provider onlineI do not have a preference on how I meet with my providerNo, I only want to meet with my provider in personWhich therapy group would you like to join?*Anxiety and Depression Support GroupChronic Pain Support GroupGrief Support GroupInformation and Consent*Yes, I consent to share my information with BCHNo, I do not agree to share my information with BCHThe 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*Yes, I can meet this requirement.No, I cannot meet this requirement.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*$24,000 or less$24,001 to $40,000$40,001 to $53,000More than $53,000This 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*12345More than 5This 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?*YesNoPlease describe circumstances of psychiatric hospitalization(s): Have 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: Have you ever engaged in self harm behaviors (like cutting, burning, etc?)*YesNoPlease briefly describe the nature and impact of these behaviors: Do you have a history of alcohol or substance abuse?*YesNoPlease briefly describe your history of alcohol or substance abuse: Are you currently misusing alcohol or substances?*YesNoBriefly elaborate on type and frequency of current alcohol or substance use: Urgency of your request:*Prefer appointment within 2 weeksPrefer appointment within 4 weeksVery urgent request for appointment Choice of payment:*Self-payPrivate InsuranceName 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:*I am the primary insuredI am a dependent on this planFull name of account holder:* First Account holder's date of birth (MM/DD/YYYY):* 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:* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Account holder's zip code:* ZIP Code Account holder's main phone:*Account holder is my:*FatherMotherSpouseOther
