Intempo Psychiatry Consultation Request
Please fill out the form below to schedule a free 15-minute consultation call with Intempo Psychiatry. This consultation 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 Intempo Psychiatry.
Sign in to Google to save your progress. Learn more

Before completing this form, please note that Intempo Psychiatry is completely out-of-network and does not accept insurance. 

Payment is required immediately following appointments. You’ll need to keep a card on file with us at all times.

We accept cash, checks, credit cards, debit cards, and HSA/FSA cards.

 *
Required
Email address: *
Cell phone number: *
Full name: *
Age: *
Preferred pronouns: *
Required
Primary state of residence: *
How were you referred to Intempo Psychiatry?
 *
Preferred services:
 *
Preferred appointment type:
 *
Briefly describe your reason for seeking psychiatric care at this time.
 *
Are you currently taking medications to address your mental health concerns?
 *
Are you currently working with a psychiatrist or mental health provider that has the ability to prescribe medications?
 *
Our fees are as follows:

- 15-minute consultation call: FREE
- 90-minute comprehensive intake appointment: $550
- 60-minute extended followup appointment: $385
- 30-minute routine followup appointment: $275

For more information, please review the fee schedule on our website.
 *
Required

Intempo Psychiatry can give you a superbill after your appointments if you ask for one. You can send this superbill to your insurance company to see if they will reimburse you for part of the appointment cost. However, we cannot promise that they will reimburse you. It’s a good idea to check with your insurance company first to find out how their superbill process works.

 *
Required
Are you a TRICARE beneficiary?
 *
Do you have a primary or secondary Medicare or Medicaid policy?
 *

Submitting this form does not automatically schedule your consultation call. After you submit the form, click the link on the submission confirmation page to choose a time for your call.

 *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Intempo Psychiatry PLLC.

Does this form look suspicious? Report

Google Forms