• Theratpeutic Medical and Psychiatric Services
    1501 Royal Ave.  Monroe, LA 71201
    Patient Information

  • Patient Date of Birth*
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  • Insurance

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  • Were you referred to our office?

  • Primary Care Provider/Medical Information

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  • Clients that provide us with permission to contact their primary care provider will have a brief letter sent to heir provider indicating that contact has been made at our office. Diagnosis information may also be released to the physician. Do we have your permission to contact your physician? By clicking yes and signing below, you are indicating you give us permission to inform your doctor of your mental health.

  • I verify that the above information is factual and true to the best of my knowledge.  Iauthorize the doctor to emloy X-Rays, photographs, anesthetics, medicines, surgeries and other quipment or aids as he/she deems necessary in order to provider the proper patient care.  I understand that payment, proof of insurance and/or copay is due at the time of service.

    I authorize this office to apply benefits on my behalf for the covered services rendered.  Icertify that the insurance information I have provided is factual and correct.

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