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 Would you like to schedule an appointment for any of the following: Would you like to schedule an appointment for any of the following: TMS Spravato Addiction / Medication-assisted Treatment None of these Please give us a brief reason for scheduling an appointment 8 + 11 = Submit