Pre-Registration FormPlease 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 email@example.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 Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* Date Format: MM slash DD slash YYYY How did you hear about us?*Friend or FamilyPrevious PatientPrimary DoctorSMHWI WebsiteGoogleFacebookLinkedInPsychology TodayOtherWho referred you?*Primary Medical Provider*Current Insurance*Secondary InsurancePhone*Email* Preferred Date* Date Format: MM slash DD slash YYYY Preferred TimeMorningAfternoonEveningNature of VisitPlease upload images of your insurance card front and back, and a copy of your license below: Drop files here or CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.