Consultation Request
This form is provided as a way to make the process of getting accepted into the practice more simple and efficient, but it can only be used if you agree that providing this information does not mean any doctor/therapist-patient/client relationship is being formed, and that no guarantee is provided that you will indeed be accepted into the practice. 

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, do not use this service. Instead, call 911 or go to your closest emergency room.
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Email *
First Name *
Last Name *
Date of birth *
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Best Phone Number for communication

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How were you referred to me?
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Reason for seeking care:

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What kind of care is being sought?
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Please list any psychiatric disorders you have been diagnosed with
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Please list CURRENT psychiatric medications:
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Please list PAST psychiatric medication:
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Please list any medical conditions you have been diagnosed with:
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What will be the primary payment method?  *
If you are planning on using Insurance, we are partnered with HEADWAY, which is our billing company. After filling out this questionnaire, please make an account on Headway, who will verify your benefits and you can schedule a free 15-minute phone consultation.
https://headway.co/providers/sagar-joshi
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