New Patient Intake

Mental Health Intake Form

Please complete this confidential intake form prior to your first appointment. The information you provide helps Dr. Anne Stephen, DNP, PMHNP-BC deliver personalized, evidence-based psychiatric care. All fields marked * are required.

🔒 This is a HIPAA-protected form. Your information is transmitted securely and used only for your care. If you are in crisis or having thoughts of self-harm, please call 988 (Suicide & Crisis Lifeline) or 911 immediately.

1. Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Gender (Optional)

2. Mailing Address

Street Address

City

State

ZIP Code

3. Emergency Contact

Someone we may contact on your behalf in case of emergency.

Contact Name *

Contact Phone *

Relationship

4. Insurance Information

Used to verify coverage before your first visit. Please have your insurance card handy for accurate details.

Insurance Provider Name *

Member ID Number

Group Number

5. Consents & Acknowledgements

I consent to receive SMS messages and phone calls from Diatan Health Services regarding my appointment, including reminders, confirmations, and follow-ups. Message and data rates may apply. I understand I can reply STOP to any SMS to opt out at any time. See our Privacy Policy and Terms of Service for details. *I acknowledge that the information provided in this intake form is accurate to the best of my knowledge, and I consent to the use and disclosure of my protected health information (PHI) for treatment, payment, and healthcare operations as described in the practice's HIPAA Notice of Privacy Practices. *

By submitting this form, you agree to be contacted by Diatan Health Services regarding your mental health care. Your information is kept confidential and HIPAA-protected.