RPC New Appointment Request

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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.

Name: *

I am not currently in a crisis. (If you are currently in a crisis, please call 911 or go to the nearest ER) *

I Agree

Required

I understand that Reproductive Psychiatry and Counseling is not in-network with any commercial health insurance plans. *

We accept HSA/FSA card payments, and provide superbills for patients to request reimbursement from their health insurance provider. Patients are responsible for appointment payments. RPC has no control over whether or not a health insurance plan will cover appointment costs. Please call our clinic if you would like more information.

I understand

Required

Are you interested in learning more about therapy?

Yes

Maybe

Clear selection

Are you interested in learning more about medication?

Yes

Maybe

Clear selection

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.

Yes

Maybe

Clear selection

Is there a specific provider that you would like to see?

Kristin Lasseter, MD

Nichelle Haynes, DO

Nicole Scott, MD

Jenna Felici-West, MD

Elaine Cavazos, LCSW, PMH-C

Nalleli Cornejo, LCSW, PMH-C (Spanish-speaking)

Grace Rao, LCSW

Emily Obront, LMSW

Sara Acevedo, LMSW (Spanish-speaking)

I'm not sure

Please provide a brief description of what brings you to our clinic at this time.

Please check all of the following which are applicable

In therapy in the past

Currently in therapy

On psychiatric medications in the past

Currently on psychiatric medications

In the psychiatric hospital now or recently

Attempted suicide in the past

Recent miscarriage or loss

Currently in fertility treatment

Currently pregnant

Currently breastfeeding

Currently postpartum (up to 12 months)

Other:

How were you referred to us?

How would you prefer to be contacted regarding this request? *

Phone call

Text message

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? *

Yes

Required

What is the best email address to reach you at?

What is your date of birth?

YYYY

What is your zip code?

What gender do you identify with?

Do you have Medicare or plan on obtaining Medicare within the next year?

Yes

Maybe

Clear selection

Submit

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