NEW PATIENT REQUEST
Office Location
Provider Requested
How did you find out about us?
Name of referral source
Please fill in patient information below
First Name:
Last Name:
Middle Initial:
Address:
Address (line 2):
City:
State:
Zip Code:
Primary Contact Number:
Email Address:
Date of Birth:
Gender:
Marital Status:
Employer:
The following information can be found on your insurance card otherwise write "self pay"
Insurance Company: (or "self pay")
Policy ID Number (or self pay)
Group Number: (or NA)
Telephone number for Mental
Health/ Behavioral Health or M.H.
Telephone number for Benefits/
Customer Service/ Providers:
Please complete the following section if the insurance is under a different  name  than patient.
Policy Holders Name: (or NA)
Policy Holders DOB: (or NA)
Policy Holders Employer: (or NA)
Please leave any additional comments below
If you would like to have our
scheduling desk contact you to
discuss availability for a
NEW
PATIENT
appointment please fill out
and submit the new patient request
form.

Our scheduling desk should contact
you within 24 business hours.

If you already have a new patient
appointment scheduled and are looking
for NEW PATIENT PAPERWORK please
click the link below.

NEW PATIENT PAPERWORK
Houston Adult Psychiatry