PRE-REGISTRATION FORM Name Date of Birth Email Address Phone Address Insurance Carrier Primary Insurance ID # Primary Insurance Group # Would you like to schedule an appointment with a Psychiatric Medical Provider? Would you like to schedule an appointment with a Psychiatric Medical Provider? Yes No Would you like to schedule an appointment with a Therapist? Would you like to schedule an appointment with a Therapist? Yes No Please give us a brief reason for scheduling an appointment 15 + 3 = Submit