Make an Appointment

Psychologist:

Dr. Cynthia Arnold Dr. Michael Friedrichs Have Not Decided

Patient Information

Name:

First:

Last:

Email Address:
Work Phone:
Home Phone:
Cell Phone:
Employer:
Birthdate:

Address:	Street 1: Street 2:
	City:	State:	Zip:

Current Mental Health Concerns:

Is the patient a child under 18 years of age? Yes No

If yes, do you have LEGAL CUSTODY? Yes No

Will You Be Using Insurance? Yes No ($160/hr)

Would you like to schedule an appointment regardless of insurance coverage?
Yes No

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. We do our best to return your request within 2 business days.

Insurance Company:	BCBS ODS TriCare Other:
ID Number:
Group Number:
In which state is your insurance based?
Phone number on back of insurance card :

Insurance Card Holder Information

The card holder is the person listed first on your card.

Is card holder information the same as patient information above? Yes No

Name:

First:

Last:

Address:	Street 1: Street 2:
	City:	State:	Zip:

Email Address:
Work Phone:
Home Phone:
Cell Phone:
Employer:
Birthdate:

Enter the code as it is shown: