Consultation Request
Dr. Jennifer Bernstein
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Patient's Name *
Patient's Date of Birth *
Patient's Gender *
Patient's Phone Number *
Patient's Email Address *
How were you referred to me? *
What kind of treatment is being sought? *
Please describe what brings you to treatment. *
Are you currently in therapy? If yes, with whom? *
Are you currently taking psychiatric medication? If yes, which ones? *
Have you ever received intensive psychiatric services, including hospitalization, partial hospitalization or intensive outpatient treatment? If yes, when and for what reason?
Do you have a history of suicide attempts or self-injuring? If yes, please elaborate.
Are there any times that would NOT work for scheduling an appointment?
Dr. Bernstein does not participate in insurance plans and does not file insurance claims. Contact your insurance carrier directly to verify your out-of-network benefits and to request specific instructions for filing out-of-network claims. You will be provided a statement of service with all the codes necessary to file a claim with your insurance carrier. Dr. Bernstein cannot guarantee insurance reimbursement of any kind.

60 min Initial Consultation - $375
45 min Psychotherapy Session - $295
30 min Medication Management Follow-up - $215

I have read the above and understand that I am responsible for payment in full at the time service is rendered.

(Please note: Dr. Bernstein will respond by email within one business day. Please check your spam folder if you have not received a response.)
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