RPC New Appointment 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 RPC. Please call us at 512-982-4116 if you prefer to request an appointment by phone.
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Name: *
I am not currently in a crisis. (If you are currently in a crisis, please call 911 or go to the nearest ER) *
Required
Are you interested in learning more about therapy?
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Are you interested in learning more about medication?
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Are you currently taking a controlled substance, such as a stimulant (like amphetamine, dextroamphetamine, methylphenidate) or benzodiazepine (like lorazepam, alprazolam, clonazepam), that you may need prescribed during your new patient appointment?
There is no guarantee that our physicians will prescribe, or continue, controlled substances; however, if the RPC physician deems a controlled substance prescription appropriate, by law, a patient must be seen in person before the prescription can be submitted.
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Is there a specific provider that you would like to see?
Please provide a brief description of what brings you to our clinic at this time. If you'd prefer to discuss this privately please indicate here. 
Please check all of the following which are applicable
How were you referred to us? *
Required
We generally find texting to be the best way to get ahold of you initially. 
If you prefer us to reach out another way, please indicate here.
 *
Required
If by phone or text, what is the best number to reach you at? *
If by phone call, when is the best time to call?
Do you consent to receiving voicemails regarding your request? *
Required
What is the best email address to reach you at?
What is your date of birth?
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What is your zip code?
What gender do you identify with?
Do you have Medicare or plan on obtaining Medicare within the next year? *
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