Make an Appointment - ADHD Diagnosis | ADHD Testing - New Leaves ClinicNew Leaves Clinic

Patient/Client Information

Patient/Client Name*

First Last

Briefly describe why you are seeking mental health services at this time?*

Patient's Date of Birth*

Age of Patient / Client

If the patient/client is under 18, do you have legal custody of the child?*

A legal guardian must be present at the first meeting.

Yes
No
NA

How did you find out about us?

Internet Search
Friend
Professional Referral
School Referral

By whom were you referred?

Returning Patients/Clients

What year was your last visit?*

What was the full name on the chart?*

First Last

Which provider did you see?*

Dr. Cynthia Arnold
Dr. Michael Friedrichs
Landon Bryce, M.Ed.
Alison Craker, L.P.C.

Payment Responsibility

How are you paying for your visit?*

Insurance
Paying Privately

Insurance Information

The following information is required by the insurance company for reimbursement. They require this information for your security. After completing this form, it will be emailed to New Leaves Clinic. We will contact your insurance provider to verify your insurance coverage, then call to schedule an appointment with you.

Please note that payment is due at time of service.

Insurance Company*

BCBS

Insurance ID Number*

Insurance Group Number*

In which state is your insurance based?*

What is the service phone number on the back of your insurance card?*

Insurance Card Holder's Information

The card holder is the person listed first on your card.

Card Holder's Name*

First Last

Card Holder's Birthday*

Card Holder's Primary Phone Number*

Card Holder's Secondary Phone Number

Card Holder's Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Personal Contact Information

The following information will be used to contact you to make an appointment. Please complete this section if it differs from the Insurance Card Holder’s Information above.

Your Relationship to the Patient/Client*

Name of Person Filling Out Form*

First Last

Your Email Address*

Enter Email Confirm Email

Is contact information for you the same as the card holder information?*

Yes
No

Primary Phone Number*

Secondary Phone Number

Address*

Street Address City State / Province / Region ZIP / Postal Code Country