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New Patient Screening Form

Welcome

Below you will find our New Patient Screening Form. 

This form will take approximately 5-10 minutes to complete. 

 

Upon completing this questionnaire, our Billing Department will do a complimentary benefits verification to ensure that our clinic is able to accept your insurance. For those who are wishing to self pay/cash pay for our services, please indicate as such on this form. From there, our providers will review your completed Screening Form to determine if, based on their current caseloads, they are able to move forward with you as a patient.  

 

Please do not hesitate to reach out with any questions that you have while filling out this form.  

 

Thank you again for your interest in our clinic & we look forward to hearing from you!

New Patient Screening Form

Please complete the fields below for the person seeking services at our clinic:

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A little more about you...

Which of our psychiatric treatment options are you currently interested in (check all that apply)
Please select any current diagnosis:
Do you have a Primary Care Physician
Do you have a current therapist
Do you have a current psychiatric prescriber
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Insurance Information

Subscriber Information (who holds this policy?)

Upload File
Upload File

Please note, while these fields are not required, our billing department may not be able to verify benefits without a copy of your insurance card.  A copy will need to be emailed to: moreinfo@csipmadison.com prior to establishing as a new patient at Collaborative Solutions in Psychiatry.  Delays in uploading this information may cause delays in establishing care.

Secondary Subscriber Information (who holds this policy?)

Upload File
Upload File

Please note, while these fields are not required, our billing department may not be able to verify benefits without a copy of your insurance card.  A copy will need to be emailed to: moreinfo@csipmadison.com prior to establishing as a new patient at Collaborative Solutions in Psychiatry.  Delays in uploading this information may cause delays in establishing care.

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Thank you! A confirmation email will be sent shortly, & a member of our intake department will be in touch soon!

Still have questions?

Email our intake department today!

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