Consultation Request Form

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Questionnaire for Intakes to be completed and reviewed before scheduling appointments.

Service Disclaimer

Please note we are accepting patients for medication management however therapy is currently waitlisting/ closed.

Requestors Full Name *

Patient Demographics

Information of the person interested in services

State legal full name *

Date of Birth *

YYYY

Relationship to person completing the form *

Self

Parent

Appointed legal guardian ( has legal document stating ability to make medical decisions on behalf of patient)

Other:

Current Address *

Phone Number *

Email Address *

(Email address is required for patient portal set up)

What type of mental health services are you looking for? *

Medication Management (PMHNP / Prescriber)

Transcranial Magnetic Stimulation (TMS consult)

Insurance Holder *

I am the primary insurance holder

I am a dependent under the primary insurance holder

I am self-pay, no insurance at this time

Do you know or are you related to anyone that is currently established at the clinic? (If, yes please provide name) *

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