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Now Accepting New Telehealth & In Person Patients Patients

We accept most insurance!

917-856-6295

1233 Mall Drive, Richmond, VA 23235

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Patient Intake Form

Please complete the intake form below with as much detail as possible. Once your form is submitted, a member of our team will review it and contact you within 1–2 business days to schedule your appointment.

We look forward to supporting your journey to mental wellness.

Appointment Type You Are Requesting*

Telehealth Visit

In Person Visit

First Name*

Last name*

DOB*

Month

Day

Year

Sex*

Female

Male

Other

Marital Status*

Single

Divorced

Married

Widowed

Email*

Primary Contact Number*

Alternate Number*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Insurance Information

How Will Your Visit Be Covered?*

Cash Payment

Covered by Insurance

Insurance Plan

Member Number

Group Number

SSN (Social Security Number)*

Insured name

Contact Number*

Emergency Contact

Name*

Relationship*

Primary Contact Number*

Name*

Relationship*

Primary Contact Number*

What Service Would You Like to Schedule?

Psychotherapy

Medication Management

Psychiatric Evaluation

Psychiatric Assessment

Are You Currently Under Medical Care?*

Yes

No

If yes, why?

If yes, please describe why you are under medical care:

Health concerns/symptoms

Terms and conditions.

Signature*

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917-856-6295

HOME
OUR APPROACH
OUR EXPERTISE
SCHEDULE SESSION
CONTACT

kjohns@kjohnsconsults.com

PATIENT INTAKE FORM
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1233 Mall Drive 1st Floor, Richmond, VA 23235

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