New Patient Request

NEW PATIENT REQUEST FORM

* Indicates required field

Legal Name *

First

Last

I am 18 years of age or older *

Yes

Email *

Cell Phone Number *

Is it ok to send you text reminders of appointments, cancellations and/or paperwork that is due? *

Yes No

Reason for seeking treatment (choose all that apply) *

Psychiatric Evaluation & Medication Management Psychiatric Evaluation for 3rd Party Medical Marijuana Card Only

MMCC ID #, if request a medical marijuana card *

Payment Options *

I understand that Medicare and Medicaid plans are not accepted *

Yes

This request is not an emergency or urgent matter - I wish to proceed *

Yes

I am a resident of the following state: *

Maryland

Do you have a guardian of person or property? *

No Yes, I have a guardian of property Yes, I have a guardian of person Yes, I have a guardian of property and person

I understand this information will be sent to a non-HIPAA compliant email. Please note this is not a secure means of communication so your confidentially cannot be ensured. *

Yes

After you have been approved for services, you will receive an email with a link to the Simple Practice Healthcare Portal and instructions with how to schedule your first appointment.