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 the intake process.

Date *
Date
Legal Name of Patient *
Legal Name of Patient
Preferred Name of Patient
Preferred Name of Patient
Please select the service you are interested in:
Phone *
Phone
Address *
Address
Address
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 you have sole legal custody, you will be required to submit documentation before receiving services. If you have joint custody, any and all legal guardians with custody need to be present at the initial clinic visit. Please note that we do not do forensic evaluations.
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:
i.e. physical assault, broken items, punched a hole in the wall
Please describe the circumstances and most recent epsiode of violence
Is your child having serious problems at school either academically or socially?
We do specific treatment protocols at our agency, 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?*
Do you or your child currently use any illegal (marijuana, cocaine, ecstasy, etc) or legal (tobacco, alcohol, medical marijuana) substances of abuse?
If yes, list substances and frequency of use:
How did you hear about BACA?
Please enter your insurance ID number
After you send the information, go to the Available Appointments page to look for appointments Enter your initials here to verify that you have read our office policies and understand that we take a $100.00 non-refundable deposit which is forfeited if the appointment is canceled or you do not show up for the appointment.
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)
I would like to subscribe to the BACA newsletter