Request Appointment Full Name* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Insurance Card*Please upload pictures of the front and back of your insurance card Drop files here or Select files Accepted file types: jpg, png, Max. file size: 128 MB. Referral source: Online/Website Insurance List of Accepted Insurances: 1199 Aetna Blue Cross Blue Shield Cigna Medicare Oxford United Behavioral Health United HealthcareHiddenInsurance Name* HiddenMember ID:* Did you meet your yearly deductible?: *Choose oneYesNoHow much is your yearly deductible?:* How much is your copay?*Disclaimer: In the event your insurance does not cover the cost of the appointment, the patient is responsible Reason for Consultation: * Current Symptoms Duration of Symptoms Current Medications, if any Please check if you have any of these diagnoses: schizophrenia bipolar disorder substance abuse recent hospitalization any ongoing psychiatric disability Please check service(s) you are interested in: Medication Management Psychiatry TMS Neuromodulation Sleep Medicine Esketamine Treatment Mind-Body Wellness HiddenPreferred Time of Consultation: Urgent 1-3 weeks 4+ weeks Submission of this form does not guarantee an appointment nor the coverage of said appointment given your insurance policy* I understand
