OpenMind Behavioral Health

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Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

What sex is on your insurance policy?

For insurance verification

State

Select the state you live in

Age

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Bipolar Disorder Autism Related Concerns

What kind of care is being sought?

Psychotherapy Medication Other Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past Substance use (Currently) Substance use (In the Past) Recent psychiatric hospitalization in the past 3 months None of these apply

Currently taking medications

List medications and dosages. If none, type N/A

Limited to 600 characters

Understanding of Services

I am seeking outpatient psychiatric evaluation and/or medication management (not emergency care, disability evaluations, or court-ordered services):

Yes

Administrative

Referral source

Enter how you were referred to our services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Insurance details - Please provide Member ID, Group Number and Insurance Company

Insurance Company, Member ID, and Group number. If self-pay, type N/A

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend Any

Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.