Patient Application

Apply to become a new patient at Seaside Wellness of Navarre.

In order to provide the quality & efficient care for your individual needs, we want to ensure patients & providers are a great match for care. Please provide the information requested below so we can determine if our team may be able to meet your healthcare needs. Our clinicians will review your application along with the information provided & we will contact you in a timely manner with our decision. Please allow additional time for the review process of your application due a high volume of new patient applications.

To remain HIPAA compliant & within guidelines, please only complete this form if you are applying as yourself or a direct family member of the intended patient. If you are a provider or medical office, we ask that you instruct your patient to visit our website & apply for themself.

Thank you,
Seaside Wellness Staff

Are you applying for yourself or on behalf of someone else? *

I'm applying for myself.

I'm applying on behalf of someone else.

Applicant information *

Legal First Name *

Middle Initial *

Legal Last Name *

Date of Birth *

Age *

Assigned Sex at Birth *

Male

Female

Intersex

Street Address *

City *

State *

Zip Code *

Mobile Phone Number *

Consent to Call & Text *

Yes

Email *

Consent to Email *

Yes

What type of care are you seeking? *

Primary Care

Psychiatric Care

Counseling/Therapy

Have you ever been hospitalized for mental health? *

Yes

Please describe the hospitalization details: *

Have you ever visited a counselor/therapist before? *

Yes

Please describe your previous therapeutic experience: *

Do you have a provider preference? *

No Preference/First Available

Yes, I prefer:

Please select the provider you prefer & we will take this preference into consideration.

Are you currently under the care of another provider? *

Yes

Name of Current Provider *

Current Provider's Facility Name *

Current Provider's Facility Address *

Current Provider's Phone Number *

Current Provider's Fax Number *

Consent to Contact Current Provider *

If we do not receive consent to contact current provider for medical records, we may not be unable to accept your application.

Are you in good standing with previous provider? *

Yes

Not applicable

Name of Previous Provider *

Previous Provider's Facility Name *

Previous Provider's Facility Address *

Previous Provider's Phone Number *

Previous Provider's Fax Number *

Consent to Contact Previous Provider *

If we do not receive consent to contact previous provider for medical records, we may not be unable to accept your application.

Please explain why you are not in good standing with your previous provider: *

We require 1-2 years of medical records to be faxed to us at least two weeks prior to a scheduled appointment. *

I understand & am willing to have medical records released.

I am NOT willing to have medical records released.

More information:

Current diagnoses: *

Current Medications: *

Please be advised that per clinic policy, we only prescribe ONE (1) controlled substance per patient at any given time.

Why are you looking for care at Seaside Wellness of Navarre? *

Will this be billed under insurance? *

Yes

Insurance Name *

Insurance Policy Number *

If you have TriCARE as your insurance, list the Benefits ID number (ending in a -00, -01, etc.).

Insurance Group Number *

If you have TriCARE as your insurance, list the Benefits ID number (ending in a -00, -01, etc.).

Do you have secondary insurance? *

Yes

Secondary Insurance Name *

Secondary Insurance Policy Number *

If you have TriCARE as your insurance, list the Benefits ID number (ending in a -00, -01, etc.).

Secondary Insurance Group Number *

If you have TriCARE as your insurance, list the Benefits ID number (ending in a -00, -01, etc.).

Are you willing to be an active participant in your healthcare plan, even if recommendations are for lifestyle changes including but not limited to exercise, focusing on nutrition & preventive wellness, &/or attending therapy or counseling if deemed necessary? *

Yes

Not being an active participant &/or being noncompliant in care plans may result in discontinued services & dismissal from the practice at the degression of the provider.

I agree to willingly submit all provided information to Seaside Wellness of Navarre. All provided information is correct & up to date to the best of my knowledge.

Name

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