Name *

Please use legal name and indicate preferred name in quotations!

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Preferred Method of Contact *

Check all that apply.

Call

Text

Email

Will you be using insurance? *

Please note: I currently do not accept Excellus, BCBS, or MVP plans, but can provide a superbill for services if your plan has out of network benefits. I do not accept Medicaid or Medicare managed plans through any insurance at this time.

Yes, I have an Aetna, Cigna, United, Carelon, Oxford, or Oscar insurance plan

I will use an HSA Card

No, I'll do Self-Pay

Do you prefer appointments to be in-person or virtual? *

At this time, I am unable to prescribe controlled substances without an in-person session.

In-Person

Virtual

I'm open to either!

What services are you interested in? *

Please check all that apply.

Psychiatric evaluation for medication management

Other

Are you currently engaged in any mental health treatment? *

Check all that apply.

Yes, I have a therapist

Yes, I have a medication prescriber but am looking to transfer services

No, not right no but I would like to be connected to a therapist

No, and I do not have interest in working with a therapist

Have you had any suicide attempts in the last year? *

No

Yes

Are you currently having suicidal thoughts? *

If you are having suicidal thoughts and there is immediate concern for your safety, please call or text 988 (Suicide and Crisis Lifeline).

No

Yes

Have you had any inpatient mental health hospitalizations within the last year? *

No

Yes

Do you use any illicit substances on a regular basis that you or anyone have considered to negatively impact your life? *

This includes alcohol, marijuana, amphetamines, cocaine, opiates, etc

No

Yes