// NEW PLAYER REGISTRATION

New Patient Intake Form

The paperwork nobody likes but everyone needs. Fill this out before your first visit so we can spend that time actually talking about you — not filling out forms in a waiting room.

Section 1 of 7
1. Personal Information
If different from your legal name — what should we call you?
2. Emergency Contact
3. Insurance Information
Snap a photo or upload an image of the front and back of your card
📇
Front of Card
Tap to upload
📇
Back of Card
Tap to upload
4. Mental Health History
Check all that apply
Be as honest as you want — no wrong answers
5. Current Medications
Include name, dose, and how often you take it
6. Medical History
No judgment — we need to know for safe prescribing. Check all that apply.
Any mental health conditions that run in the family?
7. Consent & Agreement

Informed Consent for Treatment

By signing below, I acknowledge and agree to the following:

  • I am voluntarily seeking psychiatric/mental health services from Bro Therapy & Psychiatry, operated by Luis Ruiz, PMHNP-BC.
  • I understand that treatment may include psychiatric evaluation, medication management, and/or referrals for therapy.
  • I understand that no guarantees have been made regarding the outcome of treatment.
  • I have the right to ask questions about my treatment and to refuse any recommended treatment.
  • I understand that my provider may need to break confidentiality if there is risk of harm to myself or others, suspected abuse, or a court order.

Privacy & Confidentiality (HIPAA)

Your health information is protected under HIPAA (Health Insurance Portability and Accountability Act). Your personal health information will only be shared as necessary for treatment, payment, and healthcare operations, or as otherwise required by law. You may request a full copy of our Privacy Practices at any time.

Telehealth Consent

If applicable, I consent to receiving services via telehealth (video/audio). I understand that telehealth involves electronic communication, that there are potential risks including technology failures and privacy limitations, and that I may withdraw consent at any time.

Cancellation Policy

I understand that I must provide at least 24 hours notice to cancel or reschedule an appointment. Failure to do so may result in a late cancellation or no-show fee.

Type your full legal name as your electronic signature

🛡️ All information is HIPAA-protected and sent securely

✅
You're All Set
Your intake form has been submitted securely. Your provider will review everything before your first appointment. A signed PDF copy of your intake should have downloaded automatically — keep it for your records.
Book Your First Appointment →