Success Care Patient Appointment Request Form

Appointment Request Form

Please fill in the form below
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Contact & Insurance Information
Contact Number:*
E-mail
example@example.com
What Insurance Do You Have:*
Write Self if Cash Pay
Type a question*

CommercialMedicareAHCCCSSelf PayOther
Primary Care Needs?
Current PCP?*

YesNo
If Yes, who is your Primary Care?
If NO, please list needs here
Ongoing/Chronic Medical Issues?
Psychiatric Needs?
Current Psychiatrist?*

YesNo
If Yes Psychiatrist Name
Current or past psychiatric diagnosis?*

YesNo
If Yes, please list diagnosis here
Ongoing/Chronic Medical Issues?
Current psychiatric medications?*

YesNo
If Yes, please list medications here
Psychiatric Medication?
If None, are you interested in discussing medications?

YesNo
Therapist
Current Therapist?*

YesNo
If Yes Therapist Name
Substance Abuse/MAT Needs?
Substance of Choice*

HeroinOpiatesFentanylBenzosMethamphetaminesAlcoholMarijuanaKratomMDMA/MollyPsychedelicsNONEOther
Date of Last Use

MonthDayYear
Are you seeing a MAT or Substance Abuse Provider?

YesNo
If Yes, who is the Provider?
Are you interested in medications to assist with cravings or withdraw symptoms?*

YesNo
Have you previously used medications to assist?*

VivitrolSuboxoneSublocadeMethadoneNoneOther
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Appointment Request Form