YBOCS | Artful Living Psychiatry & Wellness – Mental Health Care

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Artful Living Psychiatry & Wellness Nursing and Clinical Care

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Name

Date of Birth

Sex

Phone

Email

Will You Be Using Health Insurance?

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No

Will you be Paying Cash?

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No

Insurance Provider

Plan Name

Member ID

Group ID

Address

Adddress, City, State, ZipCode

Are you the Policy Holder?

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First Name

Policy Holder First Name

Last Name

Policy Holder Last Name

Date of Birth

Front of Insurance Card

Back of Insurance Card

What days work best for your Appointment?

Monday
Tuesday
Wednesday
Thursday
Friday

What time of day works best for your Appointment?

12:00PM-03:00PM
03:00PM-05:00PM
05:00PM-07:00PM

Reason for Visit?

ADD/ADHD
Addiction/Substance Abuse
Anxiety
Bipolar Disorder
Depression
Panic Disorder
Prescription/Refill
Post-traumatic stress disorder (PTSD)
Stress
Trauma
Other

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