Patient Service Request Form and Portal Access

Established Patient Portal Access:

https://app.carepaths.com/

For new patients, upload your documents here:

Click on: https://app.carepaths.com/
Enter Invitation Code: Zen-5089 to self register and upload documents

Please enable JavaScript in your browser to complete this form.

Patient Info

Patient Name

First

Last

Gender

Date of Birth

SSN

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Emergency Contact

Emergency Contact name

Name / Relationship

Emergency Contact Phone

Insurance / Payment

Initials Psychiatric are

Insurance or Method of Payment

Include Insurance ID Number, Group holder name and DOB or other payment method

Service Request Details

What type of service are you seeking?

What are your primary concerns?

Describe reason for seeking care

Current Psychiatric Medication History

Current medications / psychiatric history

Previous Psychiatric Medication History

Medication trials, hospitalization or treatment programs

Disclaimer and Acknowledgement

Please note: submission of this form does not create a provider-patient relationship. You will receive an email with available appointments as the providers' clinical availabilities. Due to the volume of requests, requests are reply as first-come-first serve basis.

Name or Initials

Acknowledgement of Disclaimer

Patient Info

Emergency Contact

Insurance / Payment

Service Request Details

Disclaimer and Acknowledgement

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