YOUR DETAILS:

Please fill in your personal and contact details

Full Name:*
For billing/insurance purposes, we must have your legal name exactly as it appears on your insurance ID Card

Phone:*

Email:*

Date of Birth:*

Address

City

ZIP code

Gender (optional)MaleFemale

Are you a new patient?*YesNo

Please specify the best time to contact you:ampmanytime

May we leave a message:*YesNo

INSURANCE DETAILS:

State N/A if you do not have insurance

Insurance Provider:*

Insurance Plan:*

Insurance Number:*

Insured/subscribers name:*

Relationship to insured:*

Date of Birth of Insured:*

ARE WE RIGHT FOR YOU:

Are you on psychiatric medication?YesNo

If yes, what medications are you currently taking?

Do you have any history of drug or alcohol abuse?YesNo

Have you been previously psychiatrically hospitalized?YesNo

Are you presently suicidal?YesNo

Do you think of hurting yourself?YesNo

APPOINTMENT PREFERENCE:

Please let us know your preferences for your appointment below.

Appointment Day:*Mon, Tus, ThuWed, SatSundayFirst Available

Appointment time:*AMPMor First Available

Reason for your Appointment? ie. Depression, Family conflict etc This question is optional and confidential. It will help us connect you with the therapist most suited to your needs.

Uplaod File:

I agree to the Staley Health Services terms and conditions. Staley Health Services will not share your information with any 3rd party entities.