New Client Registration

Date of Inquiry *

How did you hear about us *

Social Media

Doctor Referral

Friend/Relative

Google Search

School

Other

Welcome to NewPath Therapy & Wellness!

Thank you for reaching out to us for your mental wellness needs. You are in the right place and we are here to help you.

This is the quickest and most efficient method for scheduling an appointment with one of our clinicians. Once completed, we will be notified and contact you to schedule an appointment by phone, text, or email.

New Client Demographics

Last Name *

First Name *

Date of birth *

Gender *

Female

Male

Address *

City *

State *

Postal code *

Phone *

Email *

*If client is under 18 years of age, enter guardian information below.

Guardian Name

Guardian Date of Birth

Guardian Phone

Guardian Email

For minor clients of divorced/separated parents (or with court-ordered guardians) ONLY. *Scan or take a picture of the most recent custody section of any court paperwork.

(PLEASE NOTE: The state of Texas requires a licensed mental health professional to attempt to obtain a copy of court-ordered custody agreements to verify HIPAA rights for all parties. If these documents are not available, please let our staff know and they will make a note in the client file for you.) You may also email them to us at [email protected]

Basic Information

Emergency Contact

Contact Phone Number

Reason for Counseling *

Depression

Anxiety

Other mood disorder

Grief

Family relationships

Marital/Couples Counseling

Substance Abuse

Life Transition/Life Stressors

Eating Disorder

No response from potential client

Unknown/Rather not say

Do you prefer a male or female clinician? *

Male

Female

No preference

See a list of our clinicians here.

https://travelanewpath.com/our-therapy-team

Want an appointment with a specific clinician? If so, which one?

Which location do you prefer? *

Lumberton

Beaumont

Telehealth

No preference

Are you wanting psychological testing? *

Yes

Maybe

Are you interested in a psychiatry appointment (medication)? *

Yes

Unsure

Interested in medication treatment for ADHD? *

Yes

Not sure?

If inquiring about medication management, please let us know which doctor previously prescribed for you.

Affordable Options

Are you interested in (5) Complimentary Sessions? *

Yes

Maybe

Master or Doctoral Therapist are available for reduced rates as low as $50. Are you interested in this treatment option? *

Yes

Maybe

Insurance Information

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

If unable to upload card please give the following information:

Name of insurance co, subscriber name & date of birth (if different from client), member ID, group ID, and phone number on the back of the card

Please upload a picture of your driver's license or ID

Thank you so much for reaching out to NewPath!

Be sure to click "Submit" before closing out this window to ensure that your submission is received by our admin team.

We know this was a big step and want to get you set up as a NewPath client as soon as possible. If you were unable to upload your insurance card, ID, and any required court documents and want to expedite this process please submit those to the following:

TEXT at (409) 200-2220 OR EMAIL [email protected]

We value you and look forward to working with you very soon!

Captcha