Physician Assistant Appointment Request Form

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We appreciate your interest in scheduling an appointment with our psychiatric physician's assistant. After submitting the form, a member of our team will contact you shortly to confirm your appointment, discuss any additional details, and answer any questions you may have. Please ensure all provided information is accurate for efficient processing.

Thank you for choosing L & B Counseling. We look forward to assisting you on your journey to mental well-being. If you require immediate assistance or have urgent concerns, please contact local law enforcement or visit your local emergency room.

Your privacy is important to us. All information provided will be handled with the utmost confidentiality and in accordance with applicable privacy laws.

Please note that at this time, we are accepting Commercial Blue Cross Blue Shield and Aetna for visits with Lauren Smith, PA-C.

Full Name *

Email *

Phone Number *

How did you hear about us? *

Newsletter

School Talk

Social Media

Pop Up On The Website

Word Of Mouth

Attended a presentation

My Therapist at L&B Counseling

Another Counseling Practice (Please Name the Practice Below)

Physician's Office (Please Name Practice/Dr Below)

Other (Please Name Source)

If you were referred from someone, please let us know the name of that person, Doctor's office, school counselor, or other organization. You may also elaborate on "other".

Reason for Appointment *

Are you seeking therapy, medication management, or both? *

Therapy

Medication Management

Both

Are you scheduling this appointment for yourself or someone else? *

Myself

Someone else

Client's Date of Birth *

YYYY

Are you scheduling an appointment for a minor and have a legal custody agreement?

If yes, please provide this documentation to us before the intake assessment or first appointment. This helps us ensure we are providing the best possible care.

Yes, there is a custody agreement

No, there is no custody agreement

Not applicable

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Current Medications and Dosages *

Medical History: Please provide any relevant medical history or conditions

Previous Mental Health Treatment - Including therapists and psychiatrists *

Insurance *

Blue Cross Blue Shield

Self Pay

Insurance Information (If Applicable) - Provider, Policy Number

Additional Comment or Questions

Consent for Treatment *

By checking this box, you confirm your consent for treatment by our psychiatric physician's assistant.

Required

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This form was created inside of L & B Counseling.