Main Concern

We want to understand your concerns. Please list them in priority e.g. Medication treatment for Depression, ADHD or therapy for depression and considering medications or therapy only etc..

**By signing this form you agree to all FBH Policies located under the About page menu tab, as well as, being the person who has legal rights to request this new patient evaluation appointment.
You are also the person who is financially responsible for the appointment(s) and agree to the FBH Financial Policy data located under the About page menu tab. Also understand my HIPAA Rights described in FBH's Policies.
***Please Note: By filling out this appointment it is not a guarantee of an appointment at FBH. New Patient openings are based on immediate clinic and provider availability. We thank you for your time and courage!

Service type & details

Patient Name Who Needs the Appointment

***NOTE*** If the patient has a Guardian, Legal Benefactor i.e. they are not of age to pay for their appointments then the next section has to be filled out by the financially responsible party.
Then proceed to the Legal Financial Benefactor, Legal Parent or Guardian Name if applicable section below.
The person Legally Responsible and/or Financially responsible for payment must fill this form out since they are accepting the financial policies must bring legal documents at time of evaluation or provide them to the person who will be the legal guardian or parent taking care of the patient seeking services.

Insurance

Please put your legal name & state drivers license# or state legal id# or official legal id informaiton and anything that can help us with getting insurance approved faster.

Legal Financial Benefactor, Legal Parent or Guardian Name if applicable

NOTE: Type NA for the First and Last name box i.e NOT APPLICABLE if this section does not apply. Please type the Name of Parent , Guardian or Power of Attorney of Patient.
The person Legally Responsible and/or Financially responsible for any insurance payment or non insurance payment and legal decisions. ***NOTE***
The person Legally Responsible and/or Financially responsible for payment must fill this form out since they are accepting the financial policies must bring legal documents at time of evaluation or provide them to the person who will be the legal guardian or parent taking care of the patient seeking services.

The Person LEGALLY IN CHARGE of this Evaluation Sumbinss Acknowleges and agrees with all FBH Policy forms and rules PAYMENT for themselves or the person they are caring for who is minor or not able to make legal decissons or have legal responsibilty for payments.
Only fill this section if you are a For example the Parent, Guardian or Caregiver or Legally/Financially responsible for someone.
Otherwise, we presume that you are an adult who is totally responsible for yourself seeking services on your own and financially responsible for your own services.

Address of Person Legally in Charge of Payments

Please TYPE (NA) for Not Applicable if the patient is the same person as the one legally inchage of insurance payments or self payments. Thank you.

Please Type " NA " if not applicable

Please Type " NA " if not applicable

Contact

Please do not complain about getting call backs to your questions or clinical concerns if you are not allowing us to at least leave a message on an IDENTIFIED VOICEMAIL i.e. HI MY NAME is (State your name) please leave a message after the tone. You get it.
Otherwise we have to leave a gneric message and ask you to call us e.g. someone at your number may be a patient at FBH and should call with your HIPAA CODE for important information. Thank you.

Please make sure your voice mail has identified you so we can leave a message.

Please select which Phone you prefer us to contact you when you have FBH related concerns.

CLINICAL HISTORY or INFORMATION

Please Type " NA " if not applicable

Please describe in detail the reason for changing providers.
Example: Moving to new city, did not get along because of (fill in data), doctor moved away, doctor retired etc...