Open Door Wellness Pre-Registration
Required for New Patients.  Please note we are currently unable to accept Medicaid for counseling services.
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Type Of Visit Requested *
Were you referred from your PCP or another provider? *
Required
If referred, please provide name and relevant information.
If not referred how did you hear about us? (Referral) *
Patient Name *
Patient DOB *
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Mailing Address ( Street, City, State, Zip) *
Primary Patient Email
Primary Patient Phone Number *
If Patient Under 18, Guarantors Name and Phone Number
Patients SSN (Medical Only)
Do you wish for your appointments to be telehealth? (Behavioral Health Only)
Patient's Insurance
Notes:
Insurance Policy or ID Number
Group Number
Customer Service or Authorization Phone Number on back of card (Medical Appointments)
Insurance Subscriber Name and Relationship to Patient (If different from patient)
Insurance Subscribers SSN if different from patient. (Medical Appointments)
Insurance Subscribers DOB, if different from patient. (Medical Appointments)
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DD
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YYYY
If this is a family, marriage, couples counseling request, or if you have more children to list, please provide: Full Name, DOB,  and Relationship to primary family member, of all individuals involved in treatment. If mailing address and insurance differ from primary family member, please also list.
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