New Patient Registration — Serene Spirit Mental Health Care

Make a New Appointment

To start process of becoming a new patient of Serene Spirit Mental Health Care, please complete this form

First Name

Last Name

Date Of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Insurance Company

***Please email a copy of your card to office@serenespiritmhc.com

Insurance ID #

Insurance Group #

Insurance Subscriber Info

Subscriber name, DOB, and address (if different than clients)

Do you have any form of Medicare and/or disability insurance?

Current psychiatric medications, if any

Current mental health diagnoses, if known

Reason to be seen

How you heard about us?

Provider Requested

Student Preference

Are you comfortable with a student potentially joining your appointment?

Relax in our reception area while Serene Spirit Mental Health Care LLC