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Patient Registration Form – New Patients

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Patient Registration Form - New Patients

  • Lifespan Behavioral Health Services PC.


    Patient Registration Form

  • Appointment reminders are a courtesy service; all patients are responsible for remembering their scheduled appointments. We require a minimum of 24-hour notice for cancellations. Failure to do so may result in a charge for the missed appointment.
  • Guarantor if not the patient

    (financially responsible party for minor or incapacitated adult)
  • Note: By providing a phone number or email address, you are consenting to being contacted at that number or address regarding your treatment or billing information. In addition, your email will be used to invite you to join our secure patient portal.
  • Drivers License, Passport, Non-Drivers License
    Allowed file types include: jpg, png, pdf, gif, HEIC
    Maximum file size allowed: 25 MB
    If you are having a hard time uploading your ID card, please email a photo of it to intake@lsbhtherapy.com. Please include patient's name and DOB with Ins. card/photo ID. Thank you!
    Accepted file types: jpg, png, pdf, gif, heic.
  • Allowed file types include: jpg, png, pdf, gif, HEIC
    Maximum file size allowed: 25 MB
    If you are having a hard time uploading your ID card, please email a photo of it to intake@lsbhtherapy.com. Please include patient's name and DOB with Ins. card/photo ID. Thank you!
    Accepted file types: jpg, png, pdf, gif, heic.
  • Emergency Contact Information & Relationship to Patient

  • Insurance Information

  • For minor
  • The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Lifespan Behavioral Health Services or my insurance company to release any information required to process my claims.
  • This field is for validation purposes and should be left unchanged.

Greenbelt Office

7474 Greenway Center Drive
Suite 700-A
Greenbelt, MD 20770

Phone: 301-982-3437 or 301-969-4090
Fax: 301-982-9452

Olney Office

3416 Olandwood Court
Suite 201
Olney, MD 20832

Phone: 301-969-4060
Fax: 301-774-6285

Frederick Office

1003 West 7th Street
Suite 200
Frederick, MD 21701

Phone: 301-245-6300
Fax: 301-682-2539

LSBHS Services

  • Telehealth
  • Therapy
  • Transcranial Magnetic Stimulation (TMS)
  • Medication Management
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