Appointments

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:*

Employment status:*
I need help with:*
Please say more about what you need help with:*
Preferred services:*
Please say more about services you require:
Are you interested in receiving OMH services online?*
For this option, you will need to have a reliable internet connection, a laptop or mobile device with a camera and microphone, and a quiet location to meet with your provider undisturbed for the length of your appointment.

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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