Patient Application Form - The Eupatheia Center - Positive Psychological Practice

Patients Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Guardians Name

(if patient is child)

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

SMS Policy - We use business text to confirm and schedule appointments and general correspondence

By checking this box, you agree to receive SMS messages from The Eupatheia Center. You may reply STOP to opt-out at any time. Reply HELP for assistance. Messages and data rates may apply. Message frequency will vary.

Secondary Phone

(###)

###

####

Purpose of appointment:

psychological evaluation

Therapy

Both

What type of appointment would you like?

Virtual appointment

Brunswick office

Main reason for appointment:

Emotional Issues

Behavioral Issues

ADHD Evaluation

Autism Evaluation

Anxiety / Depression

PTSD

Marriage Counseling

Court Situation

Are you currently involved in legal or custody proceedings?

Yes

No

Are you currently seeking disability?

Yes

No

Payment for Services

Insurance

Self-pay