New Patient Request
Thank you for your interest in our office! Please complete the following form to request a new patient appointment. Openings for initial evaluations are available (generally) in 6 to 8 weeks. At times we can receive a high number of new patient requests; please allow as many as 7 - 10 business days for our office to get in touch with you.

If you or the person needing the appointment is in crisis, please call the Travis County Crisis Hotline at (512)472-HELP(4357) or the Williamson County Crisis Hotline BTCS at (800)841-1255.

If this is an emergent situation, please call 911.

Please note: Our office is private pay only and doesn't accept assignment of insurance benefits (but upon request we're happy to provide a walk-out receipt with all the pertinent information you'll need to submit to your insurance for any applicable out of network benefits.)

Our Initial Evaluations are scheduled as follows:
Child/Adolescent: $680 (2x 1-hour sessions)
- 1 hour session with Parent(s) only @ $340
- 1 hour session with Parent(s) + Child @ $340 (generally on a different day)

Adult: $510 (90 minute session)
Patient Name *
Patient's Date of Birth *
Parent(s) Name
(if Patient is under the age of 18)
Daytime Phone Number *
Email address *
Referred by: *
Reason for visit: *
(Please check all that apply.)
Interfering with: *
Filing for FMLA/disability time off at work, 504 /School District accommodations, or College Disability Accommodations? *
Any upcoming legal issues? (ie: court appearances, divorce or custody hearings) *
Please note: Our office does not provide legal testimony for non-established patients. If you're requesting a psychiatric evaluation for legal purposes, we're happy to refer you to a practice who provides those services. Please call our office at (512)327-3800.
Any substance abuse issues? *
Previous mental health hospitalizations? *
If previously hospitalized or visited the ER for mental health reasons, please provide name of hospital and date(s) of hospitalization and/or ER visits below:
Current medical problems (ie: heart, asthma, etc.) *
(or type "None")
Please list all medications, herbs, and nutritional supplements currently taking:
(For any prescription medications, please include name of prescriber.)
Dr. Custer's office is private pay only. He's not in-network with any insurance companies and doesn't accept assignment of insurance benefits (but upon request we're happy to provide patients with a walk-out receipt to submit to insurance for any applicable out of network benefits.) *
Any questions for our office or other information you'd like to provide?
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