Request Consultation Form for New Clients

Please fill out this form to help determine if Dr. Alpert's practice is a good fit. Dr. Alpert will review your responses thoroughly and be in touch regarding next steps.

As an Adult Psychiatrist, Dr. Alpert is only able to see individuals who are 18 or older.

Note: This form is HIPAA secure and compliant.

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Email *
I am the potential patient, or their Massachusetts medical power of attorney or legal guardian, completing this form in its entirety, without assistance from others.

(Family, friends, clinical staff, etc, are not permitted to complete this form on behalf of the potential patient.)
 *
Required
If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this service. Instead call 911, 988, or go to your closest emergency room.
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Required
PERSONAL INFORMATION
Legal first and last name (as it appears on your insurance) *
Preferred name or nickname
Date of Birth *
MM
/
DD
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YYYY
ZIP Code *
CONTACT INFORMATION
Phone Number *
Email Address *
By providing my email address, I am consenting to receiving unencrypted email communication from Michael Alpert, M.D., unless I explicitly state otherwise.
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Required
PAYMENT INFORMATION
Dr. Alpert accepts Blue Cross Blue Shield (BCBS) and Aetna through the Headway provider network for medication management visits.
 
All other visits, as well as medication management visits for people who do not have BCBS or Aetna, are paid for out-of-pocket.

FEES:
Initial Consultation and Evaluation: $500 (60 minutes)
Individual Therapy +/- Medication Management Follow-up: $400 (45 minutes)
Individual Medication Management Only Follow-up: $300 (25 minutes)
Ketamine-Assisted Psychotherapy (KAP): $1200 (3 hours)
One-Time or Second Opinion Consultation: $800 (90 minutes)
Expert Witnessing: $500/hour
Please select one of the following: *
What type of care are you seeking? (please select one) *
What is the name of your primary health insurance plan? 
 *
What is the name of your secondary health insurance plan (if applicable)
CLINICAL INFORMATION
What brings you to seek out mental health treatment at this time? *
Please list any current and past psychiatric and/or substance use diagnoses you have received (if none, please write "None" or "N/A"):
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Have you ever been treated at an inpatient psychiatric hospital, a partial hospital program (PHP), or intensive outpatient program (IOP)? 
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If "yes", please describe when, where, length of stay, and the reason for attending. If "no", please write "N/A". *
Have you ever made a suicide attempt? *
If "yes", please describe when these attempts occurred and the method(s) used. If "no", please write "N/A." *
Please check all of the following that apply to you. I am currently: *
Required
If you are seeking Ketamine-Assisted Psychotherapy (KAP), please answer the following questions
Have you had a physical exam performed in the past year? 
Clear selection
Do you have a history of any of the following (check all that apply):
If you have a history of any of the conditions listed above, please describe when they occurred and how they are currently being managed.
SCHEDULING INFORMATION
What times, if any, would NOT work for scheduling a pre-appointment 10-minute consultation call? (between Monday-Friday, 8:30am-4:30pm)
GENERAL
I understand that Dr. Alpert is prohibited by law from accepting patients with Medicare or Medicaid (including MassHealth).
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Required
I understand that Dr. Alpert does not provide clinical services with Schedule I substances (including but not limited to: MDMA, psilocybin, and cannabis) outside of the research setting, and that Dr. Alpert does not provide referrals to other providers who offer these substances. *
Required
I understand that for telehealth appointments, I must reside in Massachusetts. *
Required
Please share any additional information that would be helpful for Dr. Alpert to know:
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