By completing this form, you will be connected to an American Behavioral Representative who will refer you to a Provider who best fits your needs within one business day. If you would like to be connected to someone immediately, please call 800-925-5327. This form should not be used in the case of an emergency. Patient Name* First Last Patient's Date of Birth* Date Format: MM slash DD slash YYYY Patient Email* Contact number 1*Mobile Phone number*May we leave a detailed message at this number?*YesNoContact Number 2May we leave a detailed message at this number?YesNoPatient Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Subscriber's Employer*Please Specify Patient's Employer If ApplicableEmployer’s Parent Company, If ApplicableSubscriber Information (if different from the patient)Name First Last Date of Birth MM DD YYYY Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please Specify Subscriber's Employer if Applicable*Employer’s Parent Company, If ApplicableAppointment Information Reason for Appointment*To ensure the best possible match, please provide as much information as possible. Please describe any specific provider preferences, relevant symptoms, past issues and medication needs.Service Type*Office VisitTelephonic SessionHospital BasedAre You Currently Taking Any Psychotropic Medications?NoYesIf Yes, Is a Refill Needed?NoYesEstimated Refill TimeframeN/A1 Week2 Week3 Week4 Week5 Week6 Week