This form is for New Patient appointments only. For current patients, please visit https://lsbhtherapy.com/contact-us/ for locations and contact information. After you submit this form, a member of our team will contact you with information on how to complete the registration in our Patient Portal. Once the necessary documents are complete, we will schedule the first available appointment with one of our providers. Thank you for reaching out to us and we welcome you to our practice. Name* First Last Email* Preferred Phone Number*(###) ###-####Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code I am inquiring about services for*MyselfChildOtherDate of Birth* Month Day Year Name of Insurance CarrierAetnaBeacon Health OptionsCareFirst (Blue Shield)CIGNAJohns Hopkins / US FamilyMagellanMaryland MedicaidMedicareTricare / HumanaUnited Healthcare / United Behavioral HealthIf your insurance is not listed in our drop down menu, then we do not participate with your carrier and you will need to pay our self pay rates listed in our Fees & Insurance menu.Services Requested* Therapy Medication Management High Road Academy Students Other Comment or MessageLimit to 100 charactersTerms of Use*By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Lifespan Behavioral Health Services harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means. Yes, I want to submit this form.EmailThis field is for validation purposes and should be left unchanged. Δ