New Patient Intake Form

Send us a request for your initial appointment. Please complete the form below. We will contact you soon to schedule your initial appointment.

Fields marked with a (*) are required.

Requesting service for: *

Psychology
Coaching

Name *

Gender *

Male
Female

DOB *


Age

Person requesting appointment *

Relationship

Address *

County *

Home Phone *

Cell Phone *

Work Phone

Email *

Referred by *

Relationship

Reason for Referral *

Have you been hospitalized for mental health issues or treated in a rehab facility in the last 5 years?

Yes

No

 

How soon do you need an appointment?

Less than 72 Hours

2 weeks or less

1 month or less

Do you have a strong preference for a male, female or either provider?

Treating Physician/s *

Current medications, if any

Insurance Information

Primary Insurance Provider

ID #

Group #

Subscriber

Subscriber DOB


Relationship

Secondary Insurance (please fill out only if you have Secondary Insurance)

Insurance Provider

ID #

Group #

Subscriber

Subscriber DOB


Relationship

Appointment Time

Please select the days that are most convenient for you *

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday (limited hours)

Please select the time frame that is most convenient for you *

9am-Noon
Noon-4pm
4pm or later

Questions/Comments

 

Not all providers participate in all insurance plans.  We will do our best to find a provider who participates in your insurance plan.

 

I agree to allow  the office of Dr. Kunkle-Miller and Associates  to contact me. *

I agree