Consultation Request - Laura Burdette, M.D. LLC

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This form helps prospective patients/clients and clinicians connect more efficiently and explore whether the requested relationship will be a good fit. As clinician skill sets, availability, and financial policies vary, this form helps ensure you find the right clinician for your needs.

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 or go to your closest emergency room.

Email *

This request is not an emergency or urgent matter. I wish to proceed *

Agree

Required

Patient First Name *

Patient Last Name *

Patient Gender *

Date of Birth *

YYYY

My Relationship to Patient *

Self

Parent

Child

Partner

Other

If someone other than the patient is submitting the request, please list your name and phone number below: *

Phone Number *

How were you referred to the practice? *

Google

Psychology Today

Local referral Source

Family Member or friend

Other:

What are the main issues? *

Anger

Anxiety

Autism spectrum concerns

Attentional difficulties

Behavioral problems

Depression

Mood swings

Substance Abuse

Other:

Required

Check all of the following that are applicable *

In therapy now

On psychiatric medication now

In the hospital now or recently

In therapy in the past

Taken psychiatric medication in the past

Attempted suicide in the past

Hospitalized for psychiatric reasons in the past

Known neurologic or genetic disorder

None of the above

Required

What type of care is being sought? *

Medication

Psychotherapy

Both

Not sure

Please provide current medication list and the name of the physician prescribing your medications *

Are there any times that would NOT work for scheduling an appointment? *

Do you have any other scheduling limitations? *

Scheduling Preference *

In person

Virtual

No preference

I consent to receiving communications from Laura Burdette, M.D. via text message and email. *

Agree

I confirm that I reside within the state of South Carolina. *

Agree

Laura Burdette, MD does not participate in insurance plans. I understand I am responsible for payment in full at the time service is rendered, unless other arrangements have been made. I will be provided a statement so I may try to get some reimbursement from my insurance company if I am eligible. *

Agree

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