Book an Appointment 2

Welcome to Specialty Austin!

Please fill in the form below to request an appointment. Once received, a member from our team will reach out to confirm your appointment and next steps in 1-2 business days. Specialty Clinic of Austin offers in-person and telehealth (video) appointments. Our team will verify your insurance before the appointment and inform you of any copay or deductible. We look forward to helping you.

Legal Name(Required)

Legal First name* Legal last Name*

Mobile*(Required)

Date of birth*(Required)

Email address*(Required)

Gender at birth*(Required)

Referred by*(Required)

Address(Required)

Address* City* State* Zip Code*

Name(Required)

Emergency Contact Name*

Phone No

Emergency Contact Relationship

Preferred Appointment

Select Appointment

Name of person completing form and relationship to patient*(Required)

Reason for appointment*(Required)

Current medications and dosage*(Required)

List any medical allergies*(Required)

Primary Care Physician (Name, Phone, Address)

Preferred Pharmacy

Name

Phone No

Address

Address City State Zip

Is patient a minor?*(Required)

Yes

If the patient is a minor, please list the parents’ marital status:

Legal Guardian(s) (if applicable)

Preferred Phone No

Secondary Phone No

Email Address

Patient/Guardian's Name

Patient/Guardian's Signature

Date

Do you have any current or pending legal issues or are being advised by a court judge,parole officer, or CPS to seek mental health care or assessment?*(Required)

Yes

Please select if you have ever experienced or suffered from any of the following in the past or present? (check one or all that applies)

Thoughts of harming others*(Required)

Past

Present

Suicide ideation*(Required)

Past

Present

Alcohol abuse*(Required)

Past

Present

Substance abuse*(Required)

Past

Present

Are you using insurance?*(Required)

Yes

Insurance provider*(Required)

Insurance ID #*(Required)

Group #(if applicable)

Please upload a picture of the front and back of your insurance card.

Drop files here or

Max. file size: 50 MB.

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