NEW PATIENT APPOINTMENT FORM

FBH Online Form 2017

Congratulations! Your journey starts now. Empowerment is Great.
  • Please Turn off AUTO TEXT & SPELL CHECK

    Auto Text & Spell Check can delay your service without even realizing it. Many patients have submission problems & get frustrated due to a simple issue. Lets all get Zen about it and turn off that Tech for the form so we can get your journey started. See you soon. FBH Administration. Courage 🙂
  • ***NOTE*** If the patient has a Guardian, Legal Benefactor i.e. they are not of age to pay for their appointments then the next section has to be filled out by the financially responsible party. Then proceed to the Legal Financial Benefactor, Legal Parent or Guardian Name if applicable section below. The person Legally Responsible and/or Financially responsible for payment must fill this form out since they are accepting the financial policies must bring legal documents at time of evaluation or provide them to the person who will be the legal guardian or parent taking care of the patient seeking services.
  • Person person filling the form must be the Legal Financially Responsible Person who agrees with FBH Financial Policies.
  • Only fill this section if you are a Parent, Guardian or Caregiver or Legally/Financially responsible for someone. Otherwise, we presume that you are an adult who is totally responsible for yourself seeking services on your own and financially responsible for your own services.
  • Please list the name of your referral source e.g. if you found us through insurance, friend, current patient of FBH, family doctor etc...
  • NOTE: Type NA for the First and Last name box i.e NOT APPLICABLE if this section does not apply. Please type the Name of Parent , Guardian or Power of Attorney of Patient. The person Legally Responsible and/or Financially responsible for any insurance payment or non insurance payment and legal decisions. ***NOTE*** The person Legally Responsible and/or Financially responsible for payment must fill this form out since they are accepting the financial policies must bring legal documents at time of evaluation or provide them to the person who will be the legal guardian or parent taking care of the patient seeking services.
  • We want to understand your concerns. Please list them in priority e.g. Medication treatment for Depression, ADHD or therapy for depression and considering medications or therapy only etc..
  • Identified Voicemails Only

    This is how we will get in touch with you. Please help us by making sure your voice mail is Clearly Identified. We Only Leave Messages on Identified Voicemails.
  • Please type in any particular combination of days that are best for you e.g. Monday, Thursdays only or only weekdays etc. We will do our best to accomodate your needs.
  • PLEASE NOTE: Your voice mail must be identified so we can leave a message or send courtesy appointment reminders (patients are responsible for their own appointments and this is a courtesy service).
  • Please make sure your voice mail has identified you so we can leave a message or send courtesy appointment reminders (patients are responsible for their own appointments and this is a courtesy service).
  • Best Time(s) to contact you.
  • Please make sure your voice mail has identified you so we can leave a message.
  • Please make sure your voice mail has identified you so we can leave a message.
  • Please make sure your voice mail has identified you so we can leave a message.
  • Please select which Phone you prefer us to contact you when you have FBH related concerns.
  • Is this your first Consultation at FBH with Dr. Parvin or an FBH Provider?
  • Please describe in detail the reason for changing providers. Example: Moving to new city, did not get along because of (fill in data), doctor moved away, doctor retired etc...
  • Please describe in detail what caused the patient to be hospitalized including success and failures with the process. More details helps us with providing the best care and providers.
  • Please give details e.g. how many times has the attempted Suicide or Homicide, what causes the patient to do this, what makes it better or worse, did anyone know the patient had these behaviors, was the desire to cause lethal result or for attetion or for other reasons etc...
  • Please give details of how FBH providers will need to be involved in any legal proceedings.
  • Please Type " NA " if not applicable
  • Please Type " NA " if not applicable
  • Please Type " NA " if not applicable
  • Please Type " NA " if not applicable
  • Please Type " NA " if not applicable
  • Please Type " NA " if not applicable
  • Please Type " NA " if not applicable
  • By signing this form you agree to all FBH Policies located under the About page menu tab, as well as, being the person who has legal rights to request this new patient evaluation appointment. You are also the person who is financially responsible for the appointment(s) and agree to the FBH Financial Policy data located under the About page menu tab. ***Please Note: By filling out this appointment it is not a guarantee of an appointment at FBH. New Patient openings are based on immediate clinic and provider availability. We thank you for your time and courage!
  • Section Break

  • This field is for validation purposes and should be left unchanged.