Which state will you be in during your appointments?
*
Who is this application for?
*
First Name
*
Last Name
*
Date of birth
*
Legal Sex on Insurance
*
Gender Identity
Pronouns
Marital Status
Spouse or Partner Name
Student Status
Phone
*
Home Phone
Email
*
Address
Street Address
*
City
*
State
*
Postal Code
*
Best Time to Call
*
Contact Preference
*
Voicemail Permission
*
Consent to Contact
*
Photo ID (Please Upload Valid Photo ID)
Reason for Visit
*
Patient Narrative
Prior Treatment
*
Current Medications
Allergies
Medical Conditions
Surgeries or Illnesses
Referral Source
*
Emergency Contact Name
*
Emergency Contact Phone
*
Emergency Contact Relationship
*
Responsible Party Name
Responsible Party Relationship
Responsible Party Phone
Responsible Party Address
Guardian 1 Name
Guardian 2 Name
Occupation
Employer or School
Work Phone
How will you be paying for care?
*
Primary Insurance
*
Policy Number
Group Number
Insurance Member Services Phone
Policyholder
*
Policyholder Name
Policyholder Date of Birth
Secondary Insurance
Secondary Policy Number
Secondary Group Number
Insurance Card Front
Insurance Card Back
Visit Type
*
Preferred Days
The information I've provided is accurate and complete to the best of my knowledge.
*
Yes
I understand a photo ID and insurance card must be presented at every visit, and that co-payments and deductibles are due before I am seen.
*
I Understand
I understand appointments cancelled with less than 24 business hours' notice are billed to me ($50), and no-show appointments are billed at $100.
*
I Understand
I understand this application is a request for an appointment, not a confirmed appointment, and that Options will contact me to schedule.
*
I Understand
Typed Signature
*
If you are in crisis right now
— Do not wait for this application.
Call or text
988
(Suicide & Crisis Lifeline) or call
911
.