New Patient Appointment Request
Please complete all required fields marked with *. A member of our team will contact you within 1 business day to confirm your appointment.
First Name *
Last Name *
Date of Birth *
Gender * -- Select --MaleFemaleNon-BinaryPrefer Not to SayOther
Marital Status -- Select --SingleMarriedDivorcedWidowedSeparatedOther
Street Address *
City *
State * -- State --ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYDC
ZIP Code *
Cell Phone *
Home Phone
Work Phone
Email Address *
Preferred Contact Method * -- Select --Cell Phone CallCell Phone TextHome PhoneWork PhoneEmail
Best Time to Contact -- Select --Morning (8am–12pm)Afternoon (12pm–5pm)Evening (5pm–8pm)Anytime
Preferred Appointment Type * -- Select --Telehealth (Video)In-Person (if available)
Emergency Contact Name *
Relationship * -- Select --Spouse/PartnerParentSiblingChildFriendOther
Emergency Contact Phone *
Do you have insurance? *
Yes, I have insuranceNo, I will self-pay
If you have insurance, please complete the fields below. If self-pay, you may skip to the next section.
Primary Insurance Company
Member ID / Policy Number
Group Number
Insurance Phone Number
Policyholder's Full Name
Policyholder's Date of Birth
Relationship to Patient -- Select --SelfSpouse/PartnerParentOther
Are you a new or returning patient? * -- Select --New PatientReturning Patient
Primary Reason(s) for Seeking Care * (select all that apply)
DepressionAnxietyADHDBipolar DisorderPanic DisorderSleep DisorderTrauma / PTSDStress ManagementMedication ManagementPsychiatric EvaluationOther
Brief Description of Your Concerns
Are you currently taking any medications? -- Select --YesNo
Do you have any known allergies? -- Select --YesNoUnknown
Current Medications & Dosages (if applicable)
How did you hear about Capstone Behavioral Health Services? -- Select --Google / Internet SearchFriend or Family ReferralHealthcare Provider ReferralInsurance DirectoryFacebook / Social MediaLinkedInPsychology TodayZocdocTelehealth PlatformOther
I consent to receiving psychiatric evaluation, medication management, and related behavioral health services from Capstone Behavioral Health Services.
I understand that appointments may be conducted via telehealth (video) and I consent to receiving services through this format.
I have read and agree to Capstone Behavioral Health Services' Privacy Policy and understand how my personal health information will be used and protected in accordance with HIPAA regulations.
I authorize Capstone Behavioral Health Services to contact me by phone, text, or email to schedule appointments or communicate regarding my care.
By submitting this form, you acknowledge that this is an appointment request only and does not constitute a confirmed appointment. Our team will contact you to confirm scheduling. This form is not intended for emergency or crisis communication. If you are experiencing a mental health emergency, please call 988 (Suicide & Crisis Lifeline) or 911, or go to your nearest emergency room.
