New Patient Forms

If you are a New Patient to Alevea please fill out the fields below. Please be advised some of the questions are required in order to submit the form. If for any reason you cannot fill this form out please print the paper version and fax to 602-419-3101 or email to info@aleveamentalhealth.com or bring to your appointment. If you cannot print the forms, please arrive 20 minutes prior to your appointment to fill out in the lobby. Thank you for scheduling an appointment and we appreciate the opportunity to meet your needs.  

Gender
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Tobacco History
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Alcohol History
How did you Schedule?
Upload Waivers or Bring to appointment
Must be PDF. Max File Size 15MB
I have read and accept the Benzodiazepine Policy
Contact

Send us a message

A staff member will reply as soon as possible

Please do not send any personal Health Information

CALL THE OFFICE 480-247-7476 IF YOU NEED TO SPEAK WITH A STAFF MEMBER REGARDING PRIVATE HEALTH INFORMATION 

    Southern Avenue Medical Center

    2034 East Southern Ave. Suite D

    Tempe, Arizona 85282

    ​​Tel: 480-247-7476

    Fax: 602-419-3101

    Billing: (855) 689-8166 or patientbilling@kareo.com

    i​nfo@aleveamentalhealth.com

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    Arizona State University

    hotline

    (480) 921-1006

    Empact Suicide Line

    24 hours / 7 days (480) 784-1500 

    © 2017 ALEVEA Mental Health. All Rights Reserved