Isoke Method Website New Client Inquiry Form Specification

First Name

Last Name

Preferred Name

Date of Birth

Email Address

Phone Number

Street Address

City

State

Zip Code

Preferred Contact Method

Do you have any insurance coverage?

Yes No

Primary Insurance Company

Member ID

Group Number

Policy Holder Name

Policy Holder Date of Birth

Relationship to Policy Holder

Secondary Insurance? (If you do please fill out the insurance fields below)

Secondary Insurance Company

Policy Holder Name

Member ID

Group Number

Policy Holder Date of Birth

Relationship to Policy Holder

Upload Front of Insurance Card (JPG/PNG/PDF)

Upload Back of Insurance Card (JPG/PNG/PDF)

What brings you to Isoke Method today?

If, you selected other please describe your symptoms

Current Therapist

If, you selected yes what is the name of your therapist?

Do you have a current psychiatric provider?

If, you selected yes what is the name of your psychiatric provider?

Primary Care Provider

Please list all current psychiatric medications, doses, and frequency.

What are your goals for treatment?

What would success look like over the next 6–12 months?

Appointment Preference

Preferred Days

Preferred Time

Relationship

Services Requested

Are you seeking ongoing psychiatric care?

Do you have any active legal, disability, FMLA, workers' compensation, or custody matters requiring psychiatric documentation?

Are you currently having thoughts of harming yourself? If Yes, display emergency message: 'If you are in immediate danger, call 911 or go to your nearest emergency department. Isoke Method does not provide emergency services.'

Name

Phone Number

Completing this form does not establish a provider–patient relationship.

Yes, I understand completing this form does not establish a provider-patient relationship

Insurance verification is not a guarantee of payment

Yes, I understand insurance verification is not a guarantee of payment

The client is responsible for deductibles, copays, coinsurance, and non-covered services.

Yes, I understand I am responsible for deductibles, copays, coinsurance, and non-covered services.

The client gives consent for Isoke Method to contact them.

I authorized the Isoke Method to contact me.

Isoke Method Website New Client Inquiry Form Specification

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