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.

Appointment Preferences

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.

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

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

Thank you for Contacting Mental Health Calmness.

Emergency Assistance