New Patient Information Form

As a new patient of the Berkeley Therapy Institute, you can save time by filling out your paperwork online using this private and secure form.

When you’re done, click “Print My Form” to print the completed forms.
If you’re satisfied with your printout, click “Erase My Data from Browser” to remove all your entries from your browser screen.
Be sure to sign and date the printout, and bring it with you when you come in for your first appointment.

Please note that we do not store on our website any of the information you provide.

Required fields marked with *

Personal Information

First Name *

Middle Initial

Last Name *

Gender * Male Female Please select your gender.

Date of Birth *

Employment Status *

CA Driver License # *

Social Security # *

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Marital Status *

Employer

How were you referred to Berkeley Therapy Institute? *

Contact Information

Address *

City *

State *

ZIP *

Home Phone *

Work Phone

Other Phone

Demographic Information

Because the Berkeley Therapy Institute is a non-profit community clinic, we are required to keep records on the diverse population we serve. Please complete the following:

Ethnicity *

Primary Language *

Family Size *

Monthly Family Income (before taxes) *

Financial Responsibility

Is the patient the financially responsible party? * Yes No Please select an answer.

Insurance Billing

Would you like your insurance billed? * Yes No Please select an answer.