Appointment Request Form

To request a new appointment, please fill out the form completely and a member of our administrative team will contact you regarding next steps.  If the potential patient is over 18 years of age, they must complete this form themselves.

Please know that our sites sometimes close intakes into certain services/programs due to overwhelming demand.  We strive to keep this website updated so potential patients know what our availability is.  If we are able to provide you a free needs assessment and referral to a service we offer is appropriate (but we are not able to accommodate), we will need to refer you to other clinicians/programs in the community.  We are actively recruiting psychiatrists and therapists at all three of our clinic sites in order to grow to meet the community's needs.

Current Availability:

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Before completing this form, please review our FAQ regarding our Free Needs Assessment.

Read FAQ
Please check here to indicate you have read the FAQ above
Legal Name of Patient *
Legal Name of Patient
Please enter the full legal name of the patient as written on their insurance card
Preferred Name of Patient
Preferred Name of Patient
Which Clinic(s)? *
Please indicate which clinic(s) you can attend.
Please select the service level you are interested in:
Phone *
Phone
Parent/Legal Guardian 1 Name
Parent/Legal Guardian 1 Name
Parent/Legal Guardian 2 Name
Parent/Legal Guardian 2 Name
Patient Date of Birth *
Patient Date of Birth
If the patient is 18 or older, they will need to complete this form on their own
Has your child (or yourself if over 18) ever been hospitalized for mental health issues? If yes, please provide the date(s)
Does your child (or yourself if over 18) currently have a psychiatrist, psychologist and/or therapist?
If yes, please enter the names of the current providers:
We do specific treatment protocols at our organization, and often require therapy to be done at our agency. If you have another therapist and/or psychiatrist , would you be willing to leave your current therapist and/or psychiatrist for 6 months to have a treatment course at BACA?*
How did you hear about BACA?
Please enter your insurance ID number
Enter your initials here to verify that you have read our office policies.
Insurance Subscriber *
Insurance Subscriber
Who is primary on the insurance plan?
Insurance Subscriber DOB *
Insurance Subscriber DOB
The date of birth of the primary insurance holder
Insurance Phone Number (please reference back on card)
Insurance Phone Number (please reference back on card)
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