FORMS

Let’s start with paperwork

BEFORE FILLING OUT FORMS

Here’s what to know before you get started

  • For Minor Patients: We require signatures from both parents or legal guardians, in ink. If there are custody agreements or legal documentation regarding decision-making, please provide these documents to move forward with the intake process.
  • HIPAA Release of Information: While the HIPAA Release Form is not required to start the intake process, it must be completed and submitted whenever there is a need to exchange information with other parties.
  • Insurance, if applicable: Please submit a front and back copy of your medical insurance card, as well as the card for your prescription benefits
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INTAKE PACKET

Help us understand your history so we can serve your needs

intake form icon Request Information new patient form Intake Form

sending us forms

There are a few ways to send us forms

Friendly reminder: please try and send us your forms at least 24 hours before your first appointment.

  • Email: Send scanned copies of the completed forms 
to harmony@harmonypsychiatric.com.
  • Fax: Fax the forms to us at 1-603-782-0270.
  • Mail: Mail forms to: 22 Stiles Rd, Suite 104. Salem, NH 03079
  • In-Person Drop-off: If you’re nearby, you can drop off your forms in-person. Please note our dedicated drop-off hours are Monday to Wednesday, from 9 am to 1 pm.
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CONTACT US

We all have questions; let’s start the conversation

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