Intake Request Form-TeleNP Health

Intake Request Form

To become a patient with our psychiatric services, please fill out this form. This information is intended to assist us in assessing appropriateness and/or coordinating an initial appointment. Includes a FREE email consultation. Looking for clarity about your mental health? Learn more about how our services can support you with an email consultation. At TeleNP Health, we understand that the first step can feel overwhelming. That’s why we’re offering a free introduction to our services, designed to give you the clarity you need to take control of your mental wellness. Briefly share your concerns with us, and we’ll respond with professional insights and information about how we can support you.

If this is a life-threatening situation or you have an emergency, please call 9-1-1 or go to the nearest emergency room.

I am over the age of 18 and seeking care for myself

First Name

Last Name

Sex & Gender

Date of Birth

Which one of our service states do you live in?

New Jersey

Washington

Massachusetts

Connecticut

Phone Number

What services are you inquiring about?

Holistic Psychiatry

University Psychiatry Services

Second Opinion / Consultation

Have you been in psychiatric treatment before?

Yes, looking for a new provider

Yes, but it has been a long time

No, but I was referred by another provider

No, considering it

If other, please name

What do you want us to know before your consultation ?

Optional Insurance Verification If you plan to use insurance benefits to cover your care. We will verify your eligibility of services and let you know your coverage information. Please complete the following questions in its entirety, if you are interested in an eligibility check at this time.

This information is for verification purposes only and will not be used for billing purposes at this time. Information will not be stored in our billing system unless you become a confirmed patient of TeleNP Health by completing the registration process and providing your complete billing information.

Name of Insurance Plan

Insurance Member ID

Insurance Group Number

Are you the Primary Policy Holder?

Yes

Primary Policy Holder

If you are not the Primary Card/Policy Holder (parent, spouse, guardian, etc.) , please provide their information below in order to complete verification.

Relationship to Patient

Spouse

Child of

Other Adult

Primary Holder's Name

Primary Holder's Date of Birth

Insurance Verification Disclaimer:

While TeleNP Health seeks to provide you with accurate information when verifying insurance benefits, we cannot guarantee that these details are completely accurate. Insurance benefits are subject to change for different services, providers, and dates of service. Our practice has no control over these changes to your plan. The information we provide you will be an estimate based on the date of inquiry. In addition to our verification, we encourage you to call the number on the back of your insurance card and ask your member representative about your “mental health, outpatient, office visit” benefits.

By checking I Agree below, I acknowledge my consultation request is made as a prospective client and that I will only become a client by mutual agreement. I acknowledge and understand that a client-provider relationship is only established after signing a consent for treatment and undergoing an initial evaluation.

I agree to the terms & conditions

By checking I Agree below, I acknowledge contacting TeleNP Health does not establish a client-provider relationship. This initial consultation is NOT treatment. No diagnosis or treatment interventions will be provided. This consultation is not a substitute for a thorough evaluation/examination and diagnosis. Any guidance provided during this free consultation is not medical advice and may not be fully accurate without a thorough examination by one of our licensed providers. We make no explicit or implied guarantees of specific results.

I agree to the terms & conditions

Your Signature