Get help - Athena Care

Your first name *

Your last name *

Your email *

Your phone

Your address

Address Line 1

Address Line 2

City

State

Zip Code

Are you seeking help for yourself or someone else? *

Myself
Someone else

Answer all remaining questions for the person requiring service.

Service recipient

Patient first name *

Patient's last name *

Date of birth

Gender

Patient Pronouns

Treatment

Symptoms

Choose one or more

Patient other symptoms

Have you/they been formally diagnosed in the past with a mental health condition? *

Yes
No

Conditions

Choose one or more

Patient other conditions

Have you/they ever been hospitalized for a mental health condition? *

Yes
No

Reason(s) for hospitalization

Hospitalization other

Are you/they currently being treated for a mental health condition? *

Yes
No

What type of services are you/they receiving?

Other condition

Current provider name

Current practice

Medication

Are you/they currently taking any medication(s)? *

Yes
No

What medications and dosages?

Who is prescribing these medications?

Other prescriber

Prescriber name

Are you/they taking any anti-craving medications? (Such as Subutex, Suboxone, Vivitrol, etc)

Yes
No

Are you/they pregnant or planning to become pregnant?

Yes
No

Do you/they have any history of drug or substance abuse?

Yes
No

Are you/they currently receiving treatment?

Yes
No

What setting are you/they receiving treatment?

In patient
Out patient

Scheduling

Location

Best day(s) for an appointment

Not currently open on weekends

Best time(s) for an appointment

Do you/they have health insurance?

Yes
No

Insurance company

Insurance Group ID

Insurance Member ID

Insurance card

Click or drag files to this area to upload.You can upload up to 2 files.

Optionally upload photos of the front and back of your insurance card.

Are you/they able to pay out-of-pocket for services?

Yes
No