Appointments

Request an appointment today! This form is HIPAA compliant and secure.

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Location Information

Choose an OMH office location:*

How were you referred to us?*

What 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?*

What is the name of your primary care provider?*

Identification Information

First name:*

Last name:*

Date of birth (MM/DD/YYYY):*

MM slash DD slash YYYY

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.

Choose identification type:*

Enter ID number of chosen ID type:*

Contact Information

Your street address:*

Street Address

Apartment:

Address Line 2

City:*

City

State:*

State

Zip code:*

ZIP Code

Your preferred email:*

Your preferred phone:*

Personal Information and Goals

How would you like to receive our services:*

Employment status:*

Relationship status:*

Student status:*

I 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 History

Current medications you take and their doses:*

Allergies:*

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Have you ever been hospitalized for any mental health reason?*

Please describe circumstances of your hospitalization(s):*

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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:*

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Have you ever engaged in self harm behaviors (like cutting, burning, etc?)*

Please briefly describe the nature and frequency of these behaviors:*

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Have you ever misused alcohol or any other substances?*

Are you currently misusing alcohol or substances?*

Please briefly describe your current or past history of alcohol or substance misuse:*

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Urgency of your appointment request:*

Fees and Insurance

Choice of payment:*

Who is the responsible party for your health insurance plan(s):*

Name 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?*

Name of your secondary insurance plan, and type of coverage:*

For example, AARP Medicare supplemental insurance

Secondary 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?*

Sometimes, 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:*

Street 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:*

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?*

Name of plan holder's secondary insurance plan, and type of coverage:*

For example, AARP Medicare supplemental insurance

Secondary insurance plan ID number:*

We require this information to confirm your behavioral health coverage.

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Appointments

Appointments

Location Information

Identification Information

Contact Information

Personal Information and Goals

Mental Health Care History

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Fees and Insurance

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