New Patient Request "*" indicates required fields The patient is seeking the following mental health service(s):*Medication management services for adults (ages 18+)Medication management services for pediatrics (ages 0-17)Insurance:*AetnaCareFirst / BCBS PlansBlue Cross / Blue ShieldCigna and United Healthcare / OptumJohns Hopkins EHPJohns Hopkins USFHPMedicareTricare Humana (Tricare East)MedicAidSelf PayPerson completing the form, if other than the patient: Enter the first and last name of the person completing the form if other than the patient (i.e. parent, guardian).Email Address:* Enter a valid email address where a link for new patient forms can be sent.Patient's First Name:* Enter the patient's first name.Patient's Last Name:* Enter the patient's last name.Patient's Date of Birth: MM slash DD slash YYYY Enter the patient's date of birth.Best Contact Phone Number:*Can we leave a voice message at this number?* Yes No Can we text message you at this number (for administrative purposes, only)?* Yes No What has prompted the patient or responsible party to seek treatment?*Provide information here concerning the reason for seeking medication management and/or therapy services.The provider may request that a brief conversation occur with the patient and/or responsible party to ensure that the provider can meet the patient’s needs. Please indicate the ideal days of the week and/or time(s) of the day for the phone call.* Please indicate the ideal days of the week and/or time(s) of the day for the phone call.Medication management appointments take place in person. Telehealth services may be available at the provider's discretion. I understand the above statement* I understand the above statement The submission of this form does not establish a provider-patient relationship. The information provided allows us to email a link to the new patient forms. Forms are sent within 1-2 business days. If you have not received an email, it may have been routed to the junk/spam folder by the email host.I understand the above statement* I understand the above statement NameThis field is for validation purposes and should be left unchanged.