New Patients Welcome

Patient Registration

Start your journey to better mental health. Complete this form and our team will contact you within 1 business day.

Not for emergencies

If you are in crisis, call or text 988 (Suicide & Crisis Lifeline) now. For urgent needs call us at 1-888-502-8244.

New Patient Registration

Fields marked * are required

Personal Information

Patient Photo (optional)

JPG/PNG/WEBP, max 5 MB. Used for your patient ID record. Photo is optional.

Full Legal Name *

Date of Birth *

Gender (optional)

Preferred Contact Method *

Contact Information

Email Address *

Phone Number *

City (optional)

State (optional)

ZIP (optional)

Emergency Contact

Contact Name *

Contact Phone *

Relationship *

Insurance Information

Insurance Provider (optional)

Member ID (optional)

Appointment Details

Service Needed *

Preferred Location *

Preferred Days / Times (optional)

Reason for Visit

Brief description of what brings you in *

How did you hear about us? (optional)

I consent to be contacted by Refreshing Mental Health about my registration, I acknowledge the HIPAA Notice of Privacy Practices, and I understand this form is not for emergencies. *

Please do not include highly sensitive medical details in this form. This form is not for emergencies. If in crisis, call or text 988 (US).

We'll email you a confirmation immediately. Our team will follow up within 1 business day.
Need faster help? Call 1-888-502-8244.