PATIENT INTAKE/REFERRAL INFORMATION​

Thank you for choosing CMPS for your behavioral healthcare needs.  We look forward to working with you.  Please submit the following information, and we will be in touch with you within 24 business hours.

 

Please choose Office Location: *


  PATIENT INFORMATION  
  Patient Legal Name: 
 
Date of Birth: 
 
Gender: 
  Insured/Parent/Guardian Name:
 
Date of Birth:
 
Gender:
  Cell Phone Number: 
  Other Phone Number:
  Work Phone Number:
  Address Line 1: 
  Address Line 2:
  City: 
  State: 
  Zip Code: 
  Email Address: 
  Who Referred:
  Please Check One:
  Other:
  P​rimary Insurance Company: *
 
Primary Insurance ID: *
 
Phone Number on Card:
  Secondary Insurance Company:
 
Secondary Insurance ID:
 
Phone Number on Card:
 
Services Requested:
(check all that apply)
Psychiatry (medication management)
Counseling/Therapy
Psychological or Neuropsychological Testing  
Transcranial Magnetic Stimulation (TMS)   
I’m not sure

   BRIEF CLINICAL INFORMATION (symptoms, current issues)​

  Reason for seeking services
   

  IF YOU ARE IN CRISIS and need immediate emergency attention, PLEASE CALL 911 or go to your local hospital emergency room. This intake form will not direct you to a crisis line or crisis services. It may be several hours or the next day before we can respond, verify benefits, and schedule an appointment.
 
In order to schedule and hold an appointment, we require a credit card. Please provide credit card information only when requested by phone.
(After we enter the card information, according to federal law, the actual number cannot be seen))
 
We DO accept the following insurance companies:
Medicare, Blue Cross Blue Shield, Aetna, CIGNA, United Healthcare/OPTUM.

We DO NOT accept the following insurance companies:
Medicaid, Beacon, Freedom, Value Options, Magellan, Great West, Mental Health Network