Consultation Request - The Performance Psychiatrist™
Please fill out the information below to request an appointment with The Performance Psychiatrist. Our Client Care Coordinator will reach out to you within 48 hours of receiving your completed request. This appointment request form is confidential. In compliance with the Health Portability and Accountability Act "HIPAA" (rule 104-91), please know that communications over the internet are not guaranteed to be secure.  There exists a possibility that information you include in this form can be intercepted and read by other parties besides the staff at The Performance Psychiatrist™. Please call Dr. Choulet at 480-612-8985, if you prefer to request an appointment by phone.
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Email *
Full Name *
Email address *
Age of Patient *
Cell Phone Number *
How were you referred to The Performance Psychiatrist? *
Select what services you're looking for *
Please describe the reason for seeking a consultation appointment with Dr. Choulet? *
Please list your current medications. If none, put N/A. *
I understand that The Performance Psychiatrist™ is not in-network with any commercial health insurance plans. I acknowledge that I am responsible for payment at the time of service. I will be provided with a superbill that can be submitted to insurance for possible out-of-network reimbursement.*
HSA/FSA card payments are accepted. I am responsible for payment at the time of appointment. The Performance Psychiatrist has no control over whether or not a health insurance plan will reimburse appointment costs. 
I have reviewed the fee section on The Performance Psychiatrist's website:
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