Medical and Medication Request Form

Throughout the course of therapy, biological changes that affect our moods behaviors and emotions might need to be addressed via prescription medication. We are proud to offer family health, medical management and medication management services through our specialized mental health practitioners who can utilize prescription medication and medical services in order to address any needs you may have. Your prescriber works collaboratively with your therapist which ensures you receive the highest quality of care.

THIS FORM IS FOR PRESCRIPTION MEDICATION, FAMILY HEALTH AND MEDICAL MANAGEMENT REQUESTS ONLY.

Please fill out our medication request form and a member of our team will get back to you as soon as possible.

If you have any questions don’t hesitate to call us at 216-440-2936.

Medication Request Form

Name

First Last

Preferred Name

Preferred Pronoun

Phone

Second Phone Number (If Applicable)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

PLEASE UPLOAD THE FRONT AND BACK OF YOUR DRIVER'S LICENSE

Drop files here or

Max. file size: 256 MB.

PLEASE UPLOAD FRONT AND BACK OF YOUR INSURANCE CARD

Drop files here or

Max. file size: 256 MB.

Name of Insurance Holder

Address of Insurance Holder

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth of Insurance Holder

Is the Insurance Holder Male or Female?

Relationship of insurance holder to client? (Self, Child, Spouse, etc..).

Do you have secondary/supplemental insurance?

Yes

If Yes, please enter secondary/supplemental insurance information.

Enter Insurance Company, Group Number, ID Number

Who is the policy holder for your secondary/supplemental insurance?

Self

Relative

If relative please enter policy holder's first and last name.

Enter Insurance Company, Group Number, ID Number

If relative please enter date of birth of policy holder.

Enter Insurance Company, Group Number, ID Number

If relative, please enter address of policy holder.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Nurse Practitioner Gender Preference

Male

Female

No Preference

Why are you seeking medication?

What is your medication history?

How would you like to be contacted?

Phone

Text

No Preference/All of the Above

Any additional information you feel we should know?