Intake form - Crestpoint Psychiatric Care

ALL NEW PATIENT REQUEST PLEASE FILL OUT AND SUBMIT THE INTAKE FORM BELOW. APPOINTMENT AVAILABLE WITHIN 7 BUSINESS DAYS.

First Name*

Last name*

Date of Birth*

Email*

Cell Phone Number*

Home Address (Street)*

Home Address (City)*

Home Address (State, Zip Code)*

Insurance Carrier (PRIMARY INSURANCE)*

Member ID*

Who is the person listed as the primary insured?

Self
Spouse
Parent

Full Name and Date of Birth of the primary insured. If this is you, type "self".*

Attach a copy of your insurance card(FRONT)*

Attach a copy of your insurance card(BACK)*

Do you have more than one health insurance carrier?

YES
NO

Appt consultation for Transcranial Magnetic Stimulation (TMS) used in treatment of depression and anxiety.

YES
NO

Appt consultation for Spravato (Intranasal ketamine) used in managing depression and anxiety.

YES
NO

Briefly (in a few words) state the main reason for this appointment.*

List your ALL your current Psychiatric Medications. If none, type "NONE"*

Intranasal esketamine treatment requires that you MUST have a designated driver who will pick up you from the office after your treatment as you are NOT allowed to drive for 24 hours after each treatment session. Do you have someone that you can designate as YOUR DRIVER?

YES
NO
N/A

Name of your Primary Care Doctor and Office Phone Number. If you do not have one, type "None".*

Name of your Therapist OR Counselor and Phone Number. If you do not have one, type "None".*

PLEASE NOTE: Dr. Aimua DOES NOT conduct disability assessments and WILL NOT complete disability paperwork.

Policy Noted

PLEASE NOTE: For ADD/ADHD request, you will be asked to complete a Neuropsych testing.

Policy Noted

Scroll down and read through the “INITIAL APPT F.A.Q” section.

Noted