Neisha D'Souza MD Referral Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Completion of this form will assist me in determining whether my expertise and availability may suit your needs. My practice is currently full at this time. Therefore, I will be unable to visit with you but would be happy to review your request and place you my waitlist. I will be in touch within 5 business days to confirm that you are on my waitlist. Thank you for your time.

Email *

First Name: *

Last Name: *

Date of Birth: *

YYYY

Gender Identity

Street Address: *

City: *

State: *

Zip Code: *

Primary Phone: *

I run a small mental health practice and am only readily available 3 days per week. Thus, I am not the best fit should you require intensive care or access to care more than once per week.
*

I acknowledge the statement above.

I DO NOT agree with or acknowledge the above.

Required

I am in-network with Regence BCBS, MODA, Providence and Pacific Source. Out-of-pocket pay is an option. I work with a billing team, Mind Ease Billing. Staff may reach out prior to your first visit to review the expected cost of treatment. However, it is up to you to call your insurance to verify your out of pocket costs (deductible, co-pay, etc.). Please check the box in acknowledgement.
*

I acknowledge the statement above.

I DO NOT agree with or acknowledge the above.

Required

Psychiatric assessments are comprehensive, taking place over 1-3 visits. At the conclusion of the assessment we'll discuss whether I am a good fit for ongoing care. Should I feel unable to provide the quality of care that best suits your needs, I will send you a detailed assessment with recommendations and offer support in finding another provider. Please check the box in acknowledgement.
*

I acknowledge the statement above.

I DO NOT agree with or acknowledge the above.

Required

You must be actively engaged in care with a primary care doctor (PCP) or naturopath during our work together. This allows for collaboration regarding co-occurring medical issues and necessary medical workup/monitoring. If you are without a primary care provider or naturopath, you must commit to establishing with a provider within 6 months time. Please check the box in acknowledgement.
*

I am actively engaged in care with a primary provider or naturopath.

I am not actively engaged in care with a primary provider or naturopath but agree to establish with one.

I do not wish to establish care with a primary provider or naturopath.

Required

How did you find my practice? *

Identify your primary mental health challenges? (Check all that apply) *

Anger

Attention or Cognitive Difficulties

Anxiety

Behavioral Problems

Eating Disordered Behaviors or Body Image Issues

Depression

Fatigue/Feelings of Tiredness

Grief

Hallucinations (hearing, seeing, feeling things that other people do not)

Mood fluctuations

Obsessive thoughts or Compulsions

Panic Attacks

Paranoia

Self-Harm or Self-Injury (cutting/head banging)

Sleep Difficulties

Suicidal Thoughts or Urges

Trauma

Other:

What type of care do you need? (check all that apply) *

Assessment for and Management of Medication

Psychotherapy

Not Sure

Other:

Required

In your words, describe any hopes or goals you have for psychiatric care. *

Are you currently engaged in therapy? *

yes

Which of the following apply? *

I have been hospitalized for psychiatric reasons.

I have visited the emergency room or have been hospitalized for psychiatric issues in the past 2 years.

I have participated in an Intensive Outpatient Program for psychiatric issues in the past 2 years.

I have a current or past history of self-mutilation or self-injury.

I have attempted to commit suicide in the past.

I have active issues with addiction (cannabis, alcohol, stimulants or other substances).

I have active issues with anorexia or bulimia.

None of the Above

Other:

Do you have any active or pending legal issues or disability claims? *

Yes

List any psychiatric medications you currently take (include dosages): *

Primary Insurance: *

Insurance Member ID/Policy #:

Relationship to the Insured: *

Self

Spouse/Domestic Partner

Child

Other

If you are on someone else's insurance policy, please list their 1) name 2) date of birth 3) address

If you have secondary insurance, list the insurance and ID#

Do you have any form of Medicare? *

Yes

Do you have any form of Medicaid? *

Yes

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

Forms

reCAPTCHA

Privacy Terms

This form was created inside of Neisha D'Souza MD LLC.