New Patient Forms

Before your first appointment, please complete all the following forms.  The Patient Information Form and Office Policies Form are available for online submission.  Allow at least 15 minutes to complete the Patient Information Form.  If you prefer to print a PDF and mail it to our office, please mail your forms at least 5 business days before your appointment to allow time for processing. The Document Upload allows you to upload a photo of the front and back of your insurance card and driver's license.  We recommend that you do this on your smartphone.

Only upload forms AFTER you have called to schedule an appointment

Patient Information Form

Provide your contact and insurance information, as well as details on your medical history, current concerns and current medications.

or

Office Policies Form

Learn about our office policies and acknowledge receipt of our Privacy Practices.

Document Upload

Upload images/PDFs of your insurance card (front and back) along with the front of your driver's license.  This can be done easily through your smartphone.

Additional Forms

Consent for Release of Information Form 

Spravato Forms

These links should direct you to forms you may need if you are applying for esketamine (Spravato) treatment through our office.  Please complete these forms if directed by our office staff, and then submit them to us.  Forms may be submitted through the document upload feature below or on our forms page

PHQ-9 Form

Complete form online then add total combined score.

Spravato REMS Form

Complete page 2 only and then submit to our office.

Spravato Benefits Investigation Form

Complete pages 3-6 only and then submit to our office.

Document Upload

Upload files here

© 2020 by Lott Behavioral Health, all rights reserved

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