CBHS New Patient Registration Form

First Name(*)
First name is required

Last Name(*)
Last name is required

Date of Birth(*)
/ / Valid DOB is required

Gender(*)
Please choose a gender

Street Address(*)
Street address is required

Street Address 2
Invalid Input

City(*)
City is required

State(*)
Invalid Input

Zip Code(*)
Zip code is required

Cell Phone Number(*)
A valid Cell Phone Number is required

Primary Email Address (to be used for contact and TeleHealth visits)(*)
A valid Email Address is required

Parent/Guardian (if minor)
Invalid Input

Parent/Guardian DOB (if minor)
/ / Invalid Input

Employer(*)
Invalid Input

Parent/Guardian Email Address if different than Patient (To be used for electronic statements)
A valid Email Address is required

Please list the email address of your parent or guardian if you are a minor.

Parent Street Address (if different than Patient)
Street address is required

Please list the street address 1 of your parent or guardian if you are a minor.

Parent Street Address 2 (if different than Patient)
Invalid Input

Please list the street address 2 of your parent or guardian if you are a minor.

Parent City (if different than Patient)
City is required

Please list the city of your parent or guardian if you are a minor.

Parent State (if different than Patient)
Invalid Input

Please list the state of your parent or guardian if you are a minor.

Parent Zip Code (if different than Patient)
Zip code is required

Please list the zip code of your parent or guardian if you are a minor.

Would you like to receive statements by:(*)
Please choose a gender

Primary Policy Holder Name(*)
Invalid Input

Primary Policy Holder DOB(*)
/ / Invalid Input

Primary Policy Holder Street Address 1 (if different than Patient)(*)
Street address is required

Primary Policy Holder Address 2 (if different than Patient)
Invalid Input

Primary Policy Holder City (if different than Patient)(*)
City is required

Primary Policy Holder State (if different than Patient)(*)
Invalid Input

Primary Policy Holder Zip Code (if different than Patient)(*)
Zip code is required

Primary Insurance Provider(*)
Insurance Provider name is required

Primary Policy Number(*)
Policy number is required

Primary Group Number(*)
Group number is required

Primary Insurance Company Phone Number(*)
Please only include the 10 number digits

Secondary Insurance?(*)
Invalid Input

Secondary Policy Holder Name(*)
Invalid Input

Secondary Policy Holder DOB(*)
/ / Invalid Input

Secondary Policy Holder Street Address 1 (if different than Patient)(*)
Street address is required

Secondary Policy Holder Address 2 (if different than Patient)
Invalid Input

Secondary Policy Holder City (if different than Patient)(*)
City is required

Secondary Policy Holder State (if different than Patient)(*)
Invalid Input

Secondary Policy Holder Zip Code (if different than Patient)(*)
Zip code is required

Secondary Insurance Provider(*)
Insurance Provider name is required

Secondary Policy Number(*)
Policy number is required

Secondary Group Number(*)
Group number is required

Secondary Insurance Company Phone Number(*)
Please only include the 10 number digits

Reason for visit(*)

0

Please enter a reason for your visit

Current Medications
Invalid Input

Referred By
Invalid Input

Requested Provider
Invalid Input

Previous Mental Health Provider
Invalid Input

Current or history of Substance Abuse(*)
Invalid Input

If Yes, please explain
Invalid Input

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.

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