New Patient Inquiry & Appointment Request

Patient Information

First name

Last name

Patient Date of Birth

Month

Day

Year

Phone

If the patient is under age 18:

Parent / Legal Guardian Name

Who is completing this form?

Patient

Legal Parent / Guardian

Other Authorized representative

What Can We Help You With?

What brings you to Amphyst Behavioral Health?

Please note: Amphyst Behavioral Health provides in-person outpatient psychiatric care only. We do not currently offer telehealth appointments.

Spruce Secure Messaging

Have you already created a Spruce account with Amphyst Behavioral Health?

Yes

I'm not sure

Spruce is our primary secure communication platform for new and established patients. If you have not already joined, you will be asked to create a Spruce account as part of the scheduling process so our office can communicate with you securely.

Need help getting started? Call us at 210-972-6360 and we’ll be happy to assist you.

Insurance / Payment Information

How do you plan to pay for care?

Insurance

Private pay / self pay

Unsure / other

If Insurance:

Member ID

Group ID

If TRICARE / TriWest:

Sponsor's Full Name

Sponsor's Social Security Number

Insurance Notes:

Cigna: Amphyst Behavioral Health is not currently accepting new patients using Cigna insurance. Patients with Cigna may inquire about private-pay options.

Medicaid: Amphyst Behavioral Health is not currently credentialed with Medicaid. Patients with Medicaid may inquire about private-pay options.

Certain TRICARE/TriWest plans and select HMO plans may require a referral or authorization before psychiatric services are covered. If a referral is required by your plan, it may be faxed to Amphyst at 210-401-3744.

How did you hear about Amphyst Behavioral Health?

If referred by a healthcare professional, who referred you?

Appointment Preferences

What time of day generally works the best?

Morning (8:00am - 11:00am)

Afternoon (12:30pm - 3:30pm)

No preference / Any time works!

All Amphyst appointments are provided in person at our San Antonio office during regular business hours.

New Patient Inquiry Acknowledgment

I understand that submitting this form is a request to establish care and does not create a provider-patient relationship, guarantee acceptance as a patient, or confirm an appointment.

I understand that Amphyst staff will review the information submitted and contact me regarding availability, insurance or payment information, required paperwork, and next steps.

I understand that Amphyst Behavioral Health is an outpatient psychiatric practice and is not a crisis center or emergency service. This form is not monitored for urgent or emergency concerns. If I or the patient is experiencing a psychiatric or medical emergency, I should call 911, call or text 988, or go to the nearest emergency department.

I authorize Amphyst Behavioral Health to contact me using the information provided regarding this inquiry.

I have read and understand the statements above.