Pre-Registration Form Please complete the following form to notify us about your need for treatment. Appointments are not provided until this form is completed and we are able to create a patient record in our electronic health system. We require copies of your insurance card front and back and a copy of your license to verify your identity. You can upload these images utilizing this form or send them to admissions@smhwi.com. Once these steps are completed an admissions representative will call you to schedule an appointment. When you complete this pre-registration form an email will be sent to you with instructions on how to set up your patient portal and how to complete your intake forms. Thank you!Name* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Other Untitled Email Address:* Phone Number:*Current Address **(We are only able to treat patients who reside in AZ)*** Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PLEASE ACKNOWLEDGE (by checking box) I understand SMHWI providers do not provide forensic psychiatry or therapy mandated by court order or state professional licensing boards.Untitled* Yes I acknowledge, understand, and accept the statement above. PLEASE ACKNOWLEDGE (by checking box) SMHWI accepts Medicare, although we are not in network with Medicare Advantage or Medicare Replacement plans. Medicare patient services are limited to select providers and scheduling availability may be limited. Untitled* Yes I acknowledge, understand, and accept the statement above. PLEASE ACKNOWLEDGE (by checking box) SMHWI is not in network with any AHCCCS, Mercy Care or Medicaid insurance plans. Untitled* Yes I acknowledge, understand, and accept the statement above. PLEASE ACKNOWLEDGE (by checking box) If your insurance happens to change prior, during or after an appointment at SMHWI, you will be subject to cash pay if we are out of network with the updated insurance plan. Untitled* Yes I acknowledge, understand, and accept the statement above. Please select a payment option:* Cash Pay (No Insurance) Commercial Insurance Workers Compensation Military Insurance Medicare Part A and B Medicare Part A and B with Supplemental Secondary Insurance Patient is a MINOR (Younger than 18 years old?)**If patient is a minor and parents are separated, we will require custody documentation prior to an appointment* No, patient is an adult. Yes, minor has married parents. Yes, minor has divorced parents with joint custody. (Must provide custody documents) Yes, minor has divorced parents with sole custody. (Must provide custody documents) Who referred you or source of referral:* Treatment of provider(s)/service(s) needed:*Please select the services you are interested in receiving at our practice. Psychiatric Evaluation / Medication Management (with a NP/PA) Psychiatric Evaluation / Medication Management (with a MD) *availability may be limited* Therapy (with an LPC) Couples / Family Therapy (with an LPC) Intensive Outpatient Program DUI Course Reason(s) for appointment / Additional Information:Upload front and back of insurance card, ID/Driver's License, and custody documentation if applicable**(Patients using insurance for appointments will have to provide a copy of the front and back of insurance card prior to scheduling)** Drop files here or Select files Max. file size: 256 MB, Max. files: 4. CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
