New Patient Information

  • Date Format: MM slash DD slash YYYY
  • Telephone (Home)Telephone (Work)Telephone (Mobile)E-Mail
  • Date Format: MM slash DD slash YYYY
  • EDUCATION & TRAINING

  • School NameCity, StateMajor/Area of StudyDid You Graduate
  • School NameCity, StateMajor/Area of StudyDid You Graduate
  • School NameCity, StateMajor/Area of StudyDid You Graduate
  • School NameCity, StateMajor/Area of StudyDid You Graduate
  • School NameCity, StateMajor/Area of StudyDid You Graduate
  • NameRelationshipTelephone
  • NameRelationshipTelephone
  • Insurance:

    Houston OCD Program is a self-pay treatment program. We do not accept payment from third party providers (e.g. insurance or loan companies). Individuals can contract with SJ Health Insurance Advocates, who can assist you, for a fee, in receiving some reimbursement from your insurance company. SJHIA will verify benefits, request authorization for services, and bill the insurance company so that you may receive reimbursement from your insurance company. The amount of reimbursement varies based upon what services are authorized, as well as your specific plan and policy. We cannot guarantee reimbursement, but SJHIA will assist you in accessing what reimbursement is available. Should you choose not to utilize SJHIA services, Houston OCD will not seek authorization of services on your behalf, which means that if you want to file claims for reimbursement, you will have to wait to begin this process until after discharge from treatment. After discharge, you will be provided with (upon request only) superbills that reflect diagnosis codes, procedure codes, dates of services, etc... Please note, by not using SJHIA services, you will be requesting a RETRO-AUTHORIZATION once the stay is complete. For more information about insurance coverage, please contact Janice Colmar at SJHIA at (973)740- 0023, ext 122
  • FAMILY OF ORIGIN HISTORY:

  • FatherCurrent Age (or at age of death)Highest EducationOccupation
  • MotherCurrent Age (or at age of death)Highest EducationOccupation
  • SiblingCurrent Age (or at age of death)Highest EducationOccupation 
  • MARITAL/RELATIONSHIP HISTORY:

  • NameSpouse/Partner's Age at MarriageYour Age at MarriageYour Age when Divorced or WidowedYears MarriedIs Spouse/Partner Remarried? 
  • SIGNIFICANT NON-MARITAL RELATIONSHIPS:

  • NamePerson' AgeWhen Did it Start?When Did it End?Reason for Ending? 
  • CHILDREN (Indicate which are from a previous marriage or relationship):

  • NameCurrent AgeSexSchoolGrade 
  • HISTORY OF TREATMENT:

  • NameTelephoneHow Long Have You Been Working with This Provider?Frequency of Sessions:Date of Last Session:
  • NameTelephoneHow Long Have You Been Working with This Provider?Frequency of Sessions:Date of Last Session:
  • ReasonWhen (dates)?With whom & where?Outcome