New Patient Inquiry

Our doctors have different sets of skills and expertise.  Please answer the following questions in order to assist us in providing you with a clinically appropriate match.  Filling out this questionnaire does not guarantee an appointment. In the case that we are not the best fit for you, we will try to provide you with other recommendations and referrals.  If there is a specific question that you do not feel comfortable answering, please let us know.  Everything in the questionnaire is confidential and would only be shared in accordance with HIPAA and confidentiality laws.

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Name of Patient *
Preferred Name/Chosen Name
Gender/Pronouns
 *
Patient Date of Birth *
MM
/
DD
/
YYYY
Parent name if filling out for minor
City and state you live in or frequently travel to
 *
Phone Number
 *
Email Address *
How do you prefer to be contacted?
 *
Required
What are you seeking help for?
 *
Are you interested in working with one of our
 *
Were you referred by someone
 *
Have you ever seen a psychiatrist or therapist before?  When was the last time?  If so, how was your experience?
 *
Medical conditions
 *
Medications
 *
Do you have any special needs we need to be aware of?  Yes/No?  If yes, what?
 *
Any other information you would like us to know
 *
Please confirm your understanding of the following:
We are not in-network nor do we bill directly any health insurance plans. We do offer superbills for patients and families with out-of-network benefits who wish to file for reimbursement on their own. Patients must pay for sessions with a credit card, HSA, cash, or check.  Please confirm that you are willing and prepared to pay out of pocket.
 *
Required
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