Make an Appointment

Which psychologist do you prefer? * Dr. Cynthia Arnold Dr. Michael Friedrichs First available appointment
Patient's Information
Patient's Name * First Last
Why are you seeking mental health services at this time? *
Patient's Birthday *

MM/DD/YYYY
Patient's Age *
If the patient is under 18, do you have legal custody of the child? *
Were you referred to us? * Yes No
If so, by whom:
Complete this section if you are a returning patient.
Which psychologist did you see? Dr. Cynthia Arnold Dr. Michael Friedrichs
What was the full name on the chart? First Last
What year was your last visit?
Insurance Information:

The following information is required by the insurance company for reimbursement. They require this information for your security. After completing this form, it will be emailed to New Leaves Clinic. A psychologist will contact your insurance provider to verify your insurance coverage, then call to schedule an appointment with you.
NOTE: The fields below are required, regardless of insurance coverage. If you are paying privately, use "NA" where appropriate.
Insurance Company: * BCBS MHN ODS TriCare Other
Other Insurance Company:
Insurance ID Number *
Insurance Group Number *
In which state is your insurance based?
What is the service phone number on the back of your insurance card? - (###) - ### ####
Would you like to schedule an appointment if your insurance policy does not cover mental health services? * Yes, I agree to pay privately for all services not covered by my insurance company. No, I do not want an appointment unless my insurance policy covers mental health services.
Insurance Card Holder's Information

The card holder is the person listed first on your card.
Card Holder's Name * First Last
Card Holder's Birthday *
Card Holder's Home Phone * - (###) - ### ####
Card Holder's Cell Phone - (###) - ### ####
Card Holder's Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Card Holder's Email *
Personal Contact Information

The following information will be used to contact you to make an appointment. Please complete this section if it differs from the Insurance Card Holder’s Information above.
Name of Person Filling Out Form * First Last
Your Relationship to the Patient *
Home Phone * - (###) - ### ####
Cell Phone - (###) - ### ####
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Email *

Make an Appointment

Make an Appointment

Patient's Information

Complete this section if you are a returning patient.

Insurance Information:

Insurance Card Holder's Information

Personal Contact Information