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.
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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.

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Who are you completing this form for? *
Full name: *
Age: *
Preferred pronouns: *
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Primary state of residence: *
Email address: *
Cell phone number: *
Reason for consultation: *
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