New Patient Appointment Request Form
*Please note that this form is not a guaranteed appointment.

We are currently on a waitlist for new patient appointments.

This form is the initial step to our intake process. Please fill out every question presented, as any incomplete answer may delay the intake process.

This form does not guarantee an appointment. This form intends to request an evaluation and determine whether we are the best fit for the patient.

*If you or someone you know is in an emergency crisis, dial 512-472-4357, or 911.*
Veterans Suicide Hotline: 1-800-986-1891
National Suicide Prevention Lifeline: 1-800-273-8255
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Email *
New patient's full name (Please include preferred pronouns) *
Phone number (xxx) xxx-xxxx *
Insurance (Please note that this is the full list of insurances that we accept) *
If you selected "other," please note that the options provided are the only insurances accepted, along with self pay rates. If you are in the process of switching insurances, please explain below.
Date of birth (00/00/0000) *
MM
/
DD
/
YYYY
Insurance ID number AND group number *If self pay, enter N/A* *
Primary subscriber's full name and date of birth *If you are the primary subscriber, enter "self." If self pay, enter N/A* *
Will you require FMLA paperwork? *
Legal history. i.e. custody, divorce, criminal history *
What form of treatment are you seeking? Please note: We do not provide standalone therapy/counseling. *
Required
Are you interested in Transcranial Magnetic Stimulation Therapy (TMS)?
Clear selection
Are you interested in learning more about your objective brain health (WAVi brain scan)?
Clear selection
Detailed reason for visit. Please include any previous diagnosis, testing, symptoms and referrals, if any (including name/ place of referral) *
Are you a returning patient with Austin Family Psychiatry? *
Are you currently taking any of the following medications? *
Required
Current/past psychiatric medication(s) *
Do you give Austin Family Psychiatry consent to obtain medication history? *
Is there anything else you would like us to know?
How did you hear about us?
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Thank you
We appreciate your interest and time. Our intake specialist will contact you upon review.
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