Contact Us – Mental Health Calmness

Patient Information

Patient Full Name

Date of Birth

Patient Age

State Patient Will Be Located In During Visits

Parent/Guardian Name (Required if <18)

I confirm I have legal custody/guardianship of the patient listed above.

Contact Information

Insurance

Do you have health insurance?
YesNo

Insurance Company Name

Member ID Number

Subscriber Name

Subscriber Date of Birth

Are you covered by Medicaid or Medicare?
YesNo

I acknowledge that insurance will be verified.

Required Acknowledgments

I understand that I must be physically located in PA, MD, NY, OR, FL, or DE at the time of my telehealth appointment.I understand this is a request for an appointment and does not establish a provider-patient relationship.I agree to complete all required intake paperwork through the secure portal prior to my first visit.I understand that this service does not provide 24/7 crisis coverage or walk-in emergency services.I certify that the information provided in this form is accurate to the best of my knowledge.

I have read and agree to the SMS/Text Messaging Privacy Policy and consent to receive SMS/text messages from Mental Health Calmness.

SMS/Text Messaging Privacy Policy

By providing your mobile telephone number and opting in to receive text messages from Mental Health Calmness, you consent to receive SMS messages related to appointment scheduling, appointment reminders, office communications, administrative updates, and other healthcare-related services. Message frequency may vary. Message and data rates may apply.

You may opt out of receiving text messages at any time by replying STOP. You may reply HELP for additional information or assistance. Consent to receive text messages is not a condition of receiving services.

Mobile information, telephone numbers, SMS consent, and opt-in data will not be sold, rented, shared, or disclosed to third parties or affiliates for marketing or promotional purposes. Information may be shared only with service providers as necessary to support delivery of our messaging services and as otherwise permitted or required by law.

Text messaging may not be fully secure. Patients should not use text messaging for emergencies or urgent clinical concerns. If you are experiencing a medical or psychiatric emergency, call 911, call or text 988, or go to the nearest emergency department.

Start Your Intake Request

Appointments may be available this week.

Patient Information

Contact Information

Reason for Visit

Appointment Type

Emergency Assistance

Insurance

Appointment Preferences

Appointment Timing

Preferred Time

Required Acknowledgments

SMS/Text Messaging Privacy Policy

Start Your Intake Request

Appointments may be available this week.

Patient Information

Contact Information

Reason for Visit

Appointment Type

Emergency Assistance

Insurance

Appointment Preferences

Appointment Timing

Preferred Time

Required Acknowledgments

SMS/Text Messaging Privacy Policy

Thank you for Contacting Mental Health Calmness.

Emergency Assistance