New Patient Application

ATTENTION: Our office has availability for new patient scheduling, but the space for new clients is limited. Please fill out the application form below to submit your information to the office for review. We are currently only taking Blue Cross and Blue Shield Insurance, and as of January 1, 2026, we are now accepting self-pay clients. Additionally, we only treat clients who are aged 18 and older at this time. Please note that applications are reviewed in order of receipt, and openings are offered on a first-come, first-serve basis.

Thank you for considering Alabama Behavioral Health for your mental health needs! Our office requires all potential new patients to submit an application for review. The information in the application will help our office determine your insurance coverage, the doctor’s availability for scheduling, and if we would be a good match for your care. Please be assured that any information you provide to our office is kept private. We have a 2-3 business day turnaround time for reviewing applications, but we will contact you as soon as possible regarding our availability.

Before starting the application, please be aware of the following:

We are currently only taking Blue Cross and Blue Shield Insurance at this time.
As of January 1, 2026, we are accepting cash-pay/self-pay clients on a case-by-case basis.
We only see adult clients who are aged 18 and older.

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Thank you for your response. ✨

Name

Date of Birth

Phone Number

Address (MUST INCLUDE: street address, city, state, and zip code)

Reason for Visit (example: anger, anxiety, depression, ADHD, sleep issues, etc.)

Are you employed? If so, please list your current employer.

Primary Insurance Plan

Primary Insurance Subscriber Name

Primary Insurance Subscriber DOB

Policy/ID Number (Please enter the complete Policy/ID number, including any letters.)

Group Number

Do you have a Secondary Insurance Plan? If yes, we will collect the insurance plan information from you when we contact you to set up an initial appointment.

Were you referred by someone? If so, please list who referred you to us.

Have you ever been hospitalized for any psychiatric issues? If so, please tell us when, where, and what you were hospitalized for.

Have you ever been part of a Rehabilitation Program or in any type of Detox Program? If so, please tell us when, where, and what services you received.

Have you ever had any legal problems? (Including, any and all, charges, convictions, or legal matters you have experienced.) If so, please include the nature of the legal issue and the outcome.

Do you have any history of self-harm, homicidal thoughts/attempts, or suicidal thoughts/attempts? If yes to any of these, please explain.

Have you ever seen a psychiatrist? If so, please let us know who you have seen and if you are still currently seeing the psychiatrist, why you are considering transferring your care.

Are you on any psychiatric medications currently? If so, please list them.

Any additional information you would like us to know:

IMPORTANT: Before submitting your application, please be sure that you have accurately filled out the entire form. Failure to answer the questions accurately and honestly will result in our office being unable to schedule you, or if you are seen for a visit and it is found that you were not honest on the application, you will be dismissed from the practice. For our office to best assist you in your mental health journey, it is essential that you are completely honest with us.

Thank you for your response. ✨

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