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CBHS New Patient Registration Form

Thank you for your interest in our services!

Steps:

1. Fill out basic information for registration online and submit.

All information requested is necessary for the steps of pre-qualification with our organization. CBHS has implemented the highest safety and security to protect all information provided here.

2. You will be contacted by a representative for an appointment time and further instructions (please allow 2 weeks for processing and contact).

Please note new patient appointments are booking out 30 days with one of our psychiatrist or nurse practitioners initially, therapist sessions may be made available sooner. We provide prompt return service for our established clients; therefore, we can only reserve so many spots each day for new patients entering into our practice.

Please note CBHS Physicians are not certified by the Ohio State Medical Board (House Bill 523) to recommend medical marijuana use nor will they seek any such certification in the future. Please direct medical marijuana inquiries to other certified physicians. CBHS Physicians reserve the right to decline prescribing any other medication to those who are currently using marijuana for any purpose. Please disclose all medications you are taking including over the counter, illicit use of other drugs, and supplements.
Section 1: Patient Information
Patient's Last Name: (*)
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Patient's First Name: (*)
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Patient's Middle Initial:
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Patient's Preferred Name:
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Patient's Address: (*)
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City: (*)
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State: (*)
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Zip Code: (*)
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Phone Number:(*)
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Work Number:
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Mobile Phone: (*)
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The Best Time to Contact: (*)
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Best Contact Number: (*)
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Email Address:
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Patient Date of Birth(*)
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Patient's Social Security Number:(*)
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*Required for Billing Purposes. If not provided you may assume full cost of treatment.
Please Select Appropriate Box: (*)
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If Student, Name of School:
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If Student, School City:
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If Student, School State:
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If Student, Do You Attend:
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Spouse or Parent's Name:
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Spouse or Parent's Employer:
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Spouse or Parent's Work Phone:
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Whom may we thank for referring you?
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Primary Care Physician's Name:
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Primary Care Physician's Phone:
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Primary Care Physician's Address:
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Person to contact in case of Emergency: (*)
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Emergency Contact's Phone: (*)
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Section 2: Responsible Party
Relationship to Patient: (*)
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Responsible Party's Last Name(*)
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Responsible Party's First Name(*)
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Responisble Party's Date of Birth(*)
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Responsible Party's Address: (*)
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Responsible Party's Phone Number(*)
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Responsible Party's Employer:
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Policyholder Relationship to Patient: (*)
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Policy Holder's Last Name: (*)
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Policy Holder's First Name: (*)
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Policy Holder's Middle Initial:
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Policy Holder Legal Gender(*)
Please select a gender

Policy Holder's Date of Birth(*)
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Policy Holder's Social Security Number:(*)
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*Required for Billing Purposes.
Policy Holder's Address: (*)
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Policy Holder's City: (*)
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Policy Holder's State: (*)
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Policy Holder's Zip Code: (*)
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Policy Holder's Phone Number:(*)
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Policy Holder's Work Phone:(*)
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Policy Holder's Employer:
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Employer's Address:
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Employer's City:
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Employer's State:
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Employer's Zip Code:
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Employer's Phone Number:
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Insurance Company: (*)
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Insurance ID Number(*)
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Insurance Group Number:(*)
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Insurance Company Address: (*)
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Insurance Company's Phone Number:(*)
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Patient or Guardian Name: (*)
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Do you have another Insurance Policy?(*)
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Policy Holder's Last Name:
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Policy Holder's First Name:
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Policy Holder's Middle Initial:
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Policy Holder Legal Gender
Please select a gender

Policy Holder's Date of Birth
/ / Invalid Input

Policy Holder's Social Security Number:
Invalid Input

*Required for Billing Purposes.
Policy Holder's Address:
Invalid Input

Policy Holder's City:
Invalid Input

Policy Holder's State:
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Policy Holder's Zip Code:
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Policy Holder's Phone Number:
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Policy Holder's Work Phone:
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Policy Holder's Employer:
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Employer's Address:
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Employer's City:
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Employer's State:
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Employer's Zip Code:
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Employer's Phone Number:
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Insurance Company:
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Insurance ID Number
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Insurance Group Number:
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Insurance Company Address:
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Insurance Company's Phone Number:
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Any additional Insurance information may be given at your next office visit.
 
Section 3: Patient History
Reason for Visit: (*)
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Current Medications:(*)
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Prior History of Mental Health Treatment?(*)
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If Yes, When?
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If Yes, Where?
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If Yes, Who Provided?
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Hospitalization for Mental Health Issues?(*)
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If Yes, When?
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If Yes, Where?
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Any History of Abuse?(*)
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If Yes, Please Explain:
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Drug/Alcohol Use Today?(*)
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If Yes, How Often?
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Drug/Alcohol Use In the Past?(*)
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If Yes, How Often?
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Please Explain Further:
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Section 4: Preferred Pharmacy
Preferred Pharmacy:
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Preferred Pharmacy Address:
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Preferred Pharmacy's Phone Number:
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Authorization for Patient Release of Information: Please list names of Individuals or Providers that you authorize CBHS to release patient records to on separate lines.
Names of Individuals or Providers:
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By Completing the Above Field: You understand that any additional authorizations for release will be required in writing prior to release of any patient records.
 
Section 5: Consent for Treatment and Acceptance of CBHS Policies
YOU MUST READ EACH DOCUMENT LINK BELOW!

(*)
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Client Name: (*)
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Parent / Guardian / or Authorized Representative
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About Us

We are three board certified psychiatrists who specialize in evidence based treatments for Children, Adolescents and Adults. We are proud to offer a true continuum of services and the only group in the area to offer a comprehensive array of services including inpatient and outpatient.

© 2017 Comprehensive Behavior Health Services. All Rights Reserved.

The physicians at this practice typically do not make disability determinations.
Please refer to your family physician or obtain a referral from your primary physician to a disability specialist for assistance.

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