Patient Information

First Name


Last Name


Email


Phone


Date of Birth


Gender
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Address

Street Address


City


State


ZIP Code

Emergency Contact

Name


Phone


Relationship

Insurance Information

Insurance Provider


Group Number


Insurance ID


Primary Cardholder Name


Primary Cardholder Date of Birth

Upload Documents

Upload Insurance Card Front


Upload Insurance Card Back


Upload Government ID (Front Only)


Upload Guardian Documents (if applicable)

Health History (Optional)

Briefly describe your medical or mental health history

Consents & Policies

Before submitting, please review our full Patient Consents & Policies page. You must check **all boxes** below to acknowledge and consent to each item.

Patient Consents & Policies

I have received and reviewed the Notice of Privacy Practices.
I consent to treatment at IShine Behavioral Health.
I consent to telehealth services and understand the risks and limitations.
I understand that my provider may use a secure, HIPAA-compliant service that temporarily captures session audio and uses AI-assisted technology to generate clinical notes. This is strictly for documentation purposes, and all information is handled confidentially.
I authorize the use and disclosure of my PHI for treatment, payment, and healthcare operations.
I consent to communications via phone, email, or text, understanding the privacy risks.
I understand emergency and confidentiality policies as explained.
I agree to the financial and insurance terms outlined.
I have read, understood, and agree to all Patient Consents & Policies.

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