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New Patient Paperwork
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NEW PATIENT APPOINTMENT REQUEST FORM

Please complete this form if you are interested in becoming a new patient at Community Psychiatry. To get you scheduled as quickly as possible, we need to collect some information about you so that we can best match you to one of our providers.

If you are an existing patient,contact your local office to schedule your next appointment.

Patient Name*
Patient's Date of Birth*
Patient's Gender*
Preferred Pronoun*
Address(line)
What type of service are you requesting?*
Currently Psychiatry does not accept patients seeking treatment for the sole purpose of obtaining disability benefits or patients seeking long term disability benefits

INSURANCE DETAILS

Insurance can be difficult. We are here to help

If you are experiencing an emergency or thinking about harming yourself or others, please call 911 or go to emergency room.

Please click 'Submit Form' to securely send us your information.

By clicking submit, you agree that Community Psychiatry may contact you by email, phone or text.

Contact Information

(209) 707-2029

Fax : 949-437-3046

[email protected]

Monday to Saturday: 8:00 AM - 6:00 PM

3600 Sisk Rd BLDG 3

Modesto, CA 95356, USA
1455 NW Leary Way Suite 400,
Seattle, WA 98107

Contact

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