This form is confidential and HIPAA compliant

Registration Form

Congratulations in taking the first step to start at New U Therapy Center & Family Services!

Here is a positive affirmation for you: you are one step closer, keep going, you deserve it!

Here are the instructions:

As a first step, please fill out this registration form and submit it as soon as possible

Once we receive it, we will verify your insurance within 24 hours, and we will send you additional consent paperwork to submit before we schedule your appointment

If you need any assistance in filling out your paperwork, please call us at 818-600-2034 or email us at info@newutherapy.com and we will happily help you on the spot to fill out the paperwork together.

Now take a deep breath and your path to becoming a New U is starting now!

FIRST NAME: *

LAST NAME: *

DATE OF BIRTH:*

SEX:

GENDER IDENTITY:

STATE:*

CITY:*

STREET:*

APT./UNIT #:

ZIP-CODE:*

EMAIL:*

PHONE:*

ARE YOU SEEKING SERVICES FOR YOURSELF OR SOMEONE ELSE?

Myself

Someone else

IS PATIENT A MINOR?

Yes

PREFERRED METHOD OF CONTACT

Sms

RELATIONSHIP TO PATIENT:*

EMAIL:*

PHONE:*

Parent/Guardian 1

FIRST NAME:*

LAST NAME:*

DATE OF BIRTH:*

STATE:*

CITY:*

STREET:*

APT./UNIT #:

ZIP-CODE:*

EMAIL:

PHONE:*

PREFERRED METHOD OF CONTACT

SMS

Parent/Guardian 2

FIRST NAME:

LAST NAME:

DATE OF BIRTH:

STATE:

CITY:

STREET:

APT./UNIT #:

ZIP-CODE:

EMAIL:

PHONE:

PREFERRED METHOD OF CONTACT

SMS

Parent/Guardian 3

FIRST NAME:*

LAST NAME:*

DATE OF BIRTH:*

STATE:*

CITY:*

STREET:*

APT./UNIT #:

ZIP-CODE:*

EMAIL:

PHONE:*

PREFERRED METHOD OF CONTACT

SMS

+ Add Parent/Guardian

– Remove Parent/Guardian

Parents’ marital status:

Married

Divorced

Separated

Other

Who has legal custody of the minor? (Legal custody refers to who is able to make decisions about the minor’s health appointments and care):

Mother

Father

Both

Guardian

Minor Lives with:

Mother

Father

Both

Guardian

Attaching legal custody ppw

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Please describe the reason for your visit and check all services you are requesting:

REASON:*

SERVICES:*

Psychiatry Ketamine-assisted psychotherapy IOP/PHP Not Sure Psychotherapy

TYPE OF APPOINTMENT:*

Virtual

In Person

LANGUAGE:*

LOCATION:*

CLINICIANS GENDER:

Male

Female

Other

No Preference

PREFERRED APPOINTMENT TIME:

Morning Afternoon Evening Weekends All is applicable

HOW DID YOU HEAR ABOUT US?:

FIRST NAME:*

LAST NAME:*

PHONE:*

MAY WE THANK THEM? :*

Yes

Do you want to use your insurance?

Insurance

You may still have to pay a co-pay or deductible

Self-Pay

You’ll cover 100% of the cost out of pocket

Primary Health Insurance Information

INSURANCE COMPANY:*

NAME OF ANOTHER INSURANCE COMPANY : *

ID NUMBER:*

GROUP ID NUMBER:

PRIMARY INSURED NAME:*

DATE OF BIRTH:*

SOCIAL SECURITY NUMBER:

RELATIONSHIP TO THE PRIMARY SUBSCRIBER:

INSURANCE PLAN TYPE

PPO

HMO

EPO

POS

IPA

ATTACH A COPY OF THE FRONT SIDE OF YOUR VALID PRIMARY INSURANCE ID CARD *

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ATTACH A COPY OF THE BACK SIDE OF YOUR VALID PRIMARY INSURANCE ID CARD *

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ATTACH A COPY OF THE FRONT SIDE OF YOUR VALID DRIVER’S LICENSE OR GOVERNMENT-ISSUED PHOTO ID *

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Primary Health Insurance Information

INSURANCE COMPANY:*

NAME OF ANOTHER INSURANCE COMPANY : *

ID NUMBER:*

GROUP ID NUMBER:

PRIMARY INSURED NAME:*

DATE OF BIRTH:*

SOCIAL SECURITY NUMBER:

RELATIONSHIP TO THE PRIMARY SUBSCRIBER:

INSURANCE PLAN TYPE

PPO

HMO

EPO

POS

IPA

ATTACH A COPY OF THE FRONT SIDE OF YOUR VALID PRIMARY INSURANCE ID CARD *

Upload image

Choose a photo or drag it here

ATTACH A COPY OF THE BACK SIDE OF YOUR VALID PRIMARY INSURANCE ID CARD *

Upload image

Choose a photo or drag it here

ATTACH A COPY OF THE FRONT SIDE OF YOUR VALID DRIVER’S LICENSE OR GOVERNMENT-ISSUED PHOTO ID *

Upload image

Choose a photo or drag it here

Add Secondary Health Insurance Information

Remove Secondary Health Insurance Information

* I agree to New U Therapy Center & Family Services Terms of Use

Thank you for submitting your request

We will confirm your insurance and clinicians’ availability.

We will contact you soon by e-mail or SMS to clarify the details of your request and make an appointment.

To speed up the process, you can start filling out the necessary documents now.