Request an appointment today!

This form is exclusively for those interested in becoming a patient at OptiMindHealth; if you are an established patient, please call or email us instead. Once you complete this form, we will contact you within the next business day. The form is confidential and secure. The information collected is used solely for screening and scheduling purposes. Please note that completing this form does not guarantee acceptance as a patient of OptiMindHealth, nor does it establish a provider-patient relationship. Any information provided on our website or in our responses cannot be considered medical advice or treatment. If you are experiencing a medical emergency or life-threatening situation, do not use this form; instead, call 9-1-1 for emergency assistance and follow up with your primary care provider.

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Location Information

Choose an OMH office location:*

CO: Denver CentralCO: East BoulderCO: Fort CollinsMA: Back BayMA: Coolidge CornerMT: Billings

How were you referred to us?*

My primary care doctor or nurse practitionerMy health insurance websiteMy psychiatrist or psychiatric nurse practitionerMy psychotherapy counselorOnline search engineOnline mental health provider directoryOther

What is the name of your psychiatrist or psychiatric nurse practitioner?*

What is the name of psychotherapy counselor?*

What is the name of the directory you found us in?*

How were you referred to us?*

Do you have a primary care provider?*

YesNo

What is the name of your primary care provider?*

Identification Information

First name:*

Last name:*

Date of birth (MM/DD/YYYY):*

MM slash DD slash YYYY

Legal sex:*

MaleFemale

We ask for this information as it helps us to communicate with your insurer, and to register your account with us. To tell us more about your gender identity or provide other information on how we can best address you, please complete the optional field that follows.

Elaborate on how you prefer to be addressed (optional):

Add any information you wish to share regarding your gender identity, preferred pronouns, or preferred nicknames here. This information will not be shared outside of OMH. Our entire team is committed to making everyone feel safe, welcome, and respected.

Choose identification type:*

Social Security NumberDriver's License NumberPassport Number

Enter ID number of chosen ID type:*

Contact Information

Your street address:*

Street Address

Apartment:

Address Line 2

City:*

City

State:*

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:*

ZIP Code

Your preferred email:*

Your preferred phone:*

Personal Information and Goals

How would you like to receive our services:*

I would prefer meeting online onlyI do not have a preference on how I meet with my providerI would prefer meeting in person only

Employment status:*

Working Full TimeWorking Part TimeUnemployed seeking workUnemployed not seeking workHomemakerRetired

Relationship status:*

MarriedNot married

Student status:*

Full time studentPart time studentNot a student

I need help with:*

Anxiety or nervousness

Depression or mood

Insomnia or sleep problems

Relationships or friendships

Attention or focus

Substance misuse

Other

Prefer not say

Preferred service(s) type:*

Medication management

TMS

Adult counseling

College counseling

Insomnia treatment

Psychological testing services

Trauma counseling

Couples counseling

Teen counseling

Child and family counseling

Group therapy

Please say more about how we can help you:*

Mental Health Care History

Current medications you take and their doses:*

Allergies:*

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Have you ever been hospitalized for any mental health reason?*

YesNo

Please describe circumstances of your hospitalization(s):*

Section Break

Have you ever experienced suicidal thoughts or actions?*

YesNo

Have you experienced suicidal thoughts or actions in the last 3 months?*

YesNo

Please elaborate on the frequency and intensity of these thoughts or actions:*

Section Break

Have you ever engaged in self harm behaviors (like cutting, burning, etc?)*

YesNo

Please briefly describe the nature and frequency of these behaviors:*

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Have you ever misused alcohol or any other substances?*

YesNo

Are you currently misusing alcohol or substances?*

YesNo

Please briefly describe your current or past history of alcohol or substance misuse:*

Section Break

Urgency of your appointment request:*

Prefer appointment within 1 weekPrefer appointment within 2 weeksPrefer appointment within 4 weeksVery urgent request for appointment

Fees and Insurance

Choice of payment:*

Private InsuranceMedicareMedicaidSelf-pay

Who is the responsible party for your health insurance plan(s):*

I am the responsible party for my health planI am dependent on a health plan that someone else is responsible for

Name of your primary insurance plan, and type of coverage:*

For example, Blue Cross of Texas, PPO.

Primary insurance plan ID number:*

We require this information to confirm your behavioral health coverage.

Do you have any secondary or supplemental insurance?*

YesNo

Name of your secondary insurance plan, and type of coverage:*

For example, AARP Medicare supplemental insurance

Secondary insurance plan ID number:*

We require this information to confirm your behavioral health coverage.

In addition to having your own health insurance, are you currently listed as a dependent on anyone else’s health plan?*

YesNo

Sometimes, patients under the age of 26 can still be listed on parent's insurance plan, in addition to a plan from work or school. Please confirm that you do not have any insurance benefits under any other plan.

First name of person who holds the health plan:*

First

Last name of person who holds the health plan:*

Last

Date of birth of health plan holder (MM/DD/YYYY):*

MM slash DD slash YYYY

Health plan holder's relationship to you:*

SpouseMotherFatherOther

Street address of health plan holder:*

Street Address

Apartment of health plan holder:

Address Line 2

City of health plan holder:*

City

State of health plan holder:*

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 of health plan holder:*

ZIP Code

Preferred email of health plan holder:*

Preferred phone of health plan holder:*

Name of plan holder's primary insurance plan, and type of coverage:*

For example, Blue Cross of Texas, PPO.

Primary insurance plan ID number:*

We require this information to confirm your behavioral health coverage.

Does the plan holder have any secondary or supplemental insurance?*

YesNo

Name of plan holder's secondary insurance plan, and type of coverage:*

For example, AARP Medicare supplemental insurance

Secondary insurance plan ID number:*

We require this information to confirm your behavioral health coverage.

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