Pre-Appointment Information Form

Please complete the information before calling to reserve your appointment.

Your Name

Your Email Address

Your Phone Number

Patient Name (First)

Patient Name (Last)

Sex

Patient Date of Birth
,

Custody Status

Please describe Custody and Living Situation and if you have court papers stating the legal custody status:

Has your child (or yourself, if over 18) been hospitalized for mental health issues? If yes, please provide the date:

Has your child (or yourself, if over 18) taken any psychiatric medication? If yes, please provide a list of medications:

Does your child (or yourself, if over 18) currently have a diagnosis from another provider? If yes, please list the diagnosis:

Primary Concerns / Questions

Does your child (or yourself, if over 18) currently have a psychiatrist, psychologist and/or therapist

If Yes, what are their names?

We do specific treatment protocols at our agency, and often require therapy to be done at our agency. If you have another provider, would you be willing to leave your provider for 6 months to have a treatment course at BACA

Referred by

Insurance

Insurance ID Number

After you send the information, go to the Available Appointments page to look for appointments

Enter your initials here to verify that you have read our office policies and understand that we take a $100.00 Deposit which is forfeited if the appointment is canceled or you do not show up for the appointment.