Atlantic Behavioral Specialists LLC

Patient Initial Consult Form

Thank you for reaching out to Atlantic Behavioral Specialists LLC. To ensure your privacy and security, this form has been created in compliance with HIPAA guidelines. Please complete each section as accurately as possible. Our team will review your intake form within 24 to 48 hours.

First Name *

Middle Name

Last Name *

Date of Birth *

Phone Number *

Complete Address *

Email Address *

How did you hear about Ms. Sarah? If you were referred by someone, please share their name and your relationship to them.

Primary Insurance

Name of Insurance Holder

Relationship to Insured

Please attach a clear copy of your Insurance Card picture (front and back).

Would you be interested in learning the self-pay services?

yes

What is your primary concern you would like to address?

Psychiatric History (Previous Diagnosis)

Medical History (Previous Hospitalizations)

Family History

Current Medications, if any (prescription, over-the-counter, vitamins, and supplements)

Patient Initial Consult Form

Patient Initial Consult Form

Atlantic Behavioral Specialists LLC

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