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The Center for Psychology in Ft. Myers
The Center For Psychology  ~ 12499 Brantley Commons Court, #101, Ft. Myers, FL 33907  ~  P: (239) 278-3443   F: (239) 278-3550
5633 Strand Boulevard, Suite 301-B, Naples, FL 34110

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New Patient Form

To arrange an initial appointment, please complete this form and click the "Submit" button to send to us. We will be in touch.


Information About the Patient

Patient's Name: *
Date of Birth: * (MM/DD/YYYY)
Mailing Address: *
City, State, Zip: *
Home Phone Number: *
Cell Phone Number:
Email: (for appointment reminders only)

Patient Status

Is the patient under the age of 18? *
Please provide information about the parent/guardian (or financially responsible individual).
Name: *
Address:
City, State, Zip:
Home Phone Number: *
Cell Phone Number:
Date of Birth: (MM/DD/YYYY)

Information About Your Insurance:

I would prefer to pay out-of-pocket: *
Name of Insurance Company: *
Mental Health Benefits Phone Number: *
Member ID: *

Information About the Subscriber: Insured's Name: *
Insured's Address: (If different from Patient's) *
City, State, Zip: *
Home Phone Number: *
Cell Phone Number:
Subscriber's Date of Birth: * (MM/DD/YYYY)

Other Information

Referred by:
Patient would prefer to see:
Dr. Cohen
Dr. Hurst
Dr. Vallejos
Dr. Wilmshurst
Dr. Mason
Dr. Newton
Dr. Bermudez
First Available
Most appropriate for my concerns
No Preference

Which location do you prefer:
Fort Myers
Naples

Please tell us a bit about the purpose of the visit so we can match you to the most appropriate doctor: *

By agreeing to each statement below, I....


* Authorize the Center for Psychology, PA, to share and obtain information, protected under the legislation known as HIPAA,
with my insurance company and primary care physician.
(Type YES in box to agree)

* Acknowledge having read, understood and agree to the HIPAA notification and the Terms of Agreement
that were either faxed to me or viewed at www.thecenterforpsychology.com.
(Type YES in box to agree)

* Agree to keep and be financially responsible for all appointments I make, and to pay for all missed appointments,
unless I cancel at least two days in advance.
(Type YES in box to agree)



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The Center For Psychology  ~ 12499 Brantley Commons Court, #101, Ft. Myers, FL 33907  ~  P: (239) 278-3443   F: (239) 278-3550

Psychology and Neuropsychology Practice serving Fort Myers, Cape Coral, Naples, Ft. Myers Beach, Lehigh Acres, Estero,
Bonita Springs, Sanibel, Captiva, Pine Island and surrounding areas of Lee and Collier Counties, Florida

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