New Patients

Patient Forms

All new patient forms are completed electronically through our secure patient portal. There is nothing to print or mail — our office will guide you through every step.

Spanish forms are available. If you prefer to complete your intake forms in Spanish, please let our office know when you call — we have Spanish-language forms available in office.

Appointment Request Forms

Select the form that applies to your situation. All information is kept strictly confidential.

DR. CHARLES GUTIERREZ
CHILD / ADOLESCENT APPOINTMENT REQUEST FORM
For patients under age 18
Patient Information
Today's Date
New Patient?
First Name
Middle
Last
Date of Birth
Age
Patient Adopted?
Legal Guardian
Biological Father
Biological Mother
Legal Custody
Open CPS Case?
Legal Issue (if any)
Contact Information
Home Phone
Cell Phone
Work Phone
Mailing Address
City
State
Zip Code
Email Address
Referral Source
Reason for Evaluation / Treatment
Primary Insurance Information
Insurance Company
Insured / Policy Holder
Relationship to Patient
Member / ID #
Group #
Insured DOB
Insurance Phone
Subscriber / Policy #
Secondary Insurance Information
Insurance Company
Insured / Policy Holder
Relationship to Patient
Member / ID #
Group #
Insured DOB
Insurance Phone
Subscriber / Policy #

Fields marked with * are required. Your information is protected under HIPAA and will only be used for scheduling and evaluation purposes.

What Forms to Expect

Depending on the type of evaluation, your portal invitation will include some or all of the following:

  • Patient information and demographic form
  • Medical and developmental history
  • Insurance authorization and assignment of benefits
  • HIPAA notice of privacy practices acknowledgment
  • Informed consent for evaluation
  • Release of information (as applicable)

MyIO by Valant

Secure Patient Portal

  • HIPAA-compliant and fully encrypted
  • Complete forms from any device — phone, tablet, or computer
  • Invitation sent directly to your email after scheduling
  • No account setup required before your appointment is confirmed
  • Forms must be completed prior to your first visit

Haven't received your invitation? Check your spam or junk folder, then call our office at 210-354-1186 and we'll resend it right away.

Fax

210-354-1187

Office Hours

Mon – Fri, 9AM – 4PM

Ready to Get Started?

Submit an appointment request and our office will follow up within 24 hours — including sending your portal invitation so you can complete your forms in advance.

Dr. Charles E Gutierrez

Comprehensive psychological evaluations and assessments for children, adolescents, and adults in San Antonio, TX.

Contact

Schedule a consultation today

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© 2026 Dr. Charles E. Gutierrez. All rights reserved.

Mental Health