Consultation Request

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Consultation Request

Thank you for requesting a consultation call!

This form helps determine whether I am a good fit for your individual needs, as provider skill sets and specialties vary greatly.

At this time I am accepting patients for medication management via telemedicine. In light of the constraints of virtual psychiatric care, please note that I am currently unable to accept patients with a recent history of suicide, recent inpatient hospitalization, or current severe substance use disorder.

If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this service. Instead call 911 or go to your closest emergency room

Full Name *

Phone Number *

Preferred Method of Contact

Phone Call

Any

What are the main issues you are struggling with?

Anxiety

Depression

Attentional Difficulties

Anger

Substance Abuse

Bipolar

Psychosis (Including Schizophrenia)

Other:

Please check all of the following that are applicable *

In Therapy now

In Therapy in the past

On psychiatric medication currently

On psychiatric medication in the past

Hospitalizations for psychiatric reasons in the past

Attempted suicide in the past

Have been in substance abuse treatment (ex rehab or detox)

None of the above

Required

What type of care is being sought currently? *

Medication Management

Therapy

Both

If you'd like, please provide more information about what you are hoping to get help with below

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