Consultation Request

This form helps prospective patients and clinicians connect more efficiently and explore whether the requested relationship will be a good fit. Submitting this form, any other intake forms and rating scales does not constitute the formation of a treatment relationship. We review these forms to determine if our practice is a good fit.

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.

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Email *
Patient's First Name *
Patient's Middle Name
Patient's Last Name *
Patients Date of Birth *
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Phone Number *
Patient's Full Home Address including city, state, and zip code *
Name of Primary Contact (if different from patient):
Also include who the contact is in relation to the prospective patient.
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How did you hear about the practice? *
What kind of care is being sought? *
How would you like to receive care? *
Please describe the issues that have led to seeking treatment. *
Holly Valerio, MD does not participate in insurance plans. I understand I am responsible for payment in full at the time service is rendered, unless other arrangements have been made. I will be provided a statement so I may try to get some reimbursement from my insurance company if I am eligible.
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Required
What insurance do you have currently? *
Do you have Medicare *
Do you consent to receive messages from the practice of Holly Valerio, M.D. via email and SMS text messages? *
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