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Appointment Requests for Therapy Only
Appointment Requests for Medication Management and Evaluations
Locations
Home
About
Our Mission
Our Core Values
Meet Our Founder
Meet Our Staff
Our Services
Rates and Insurance
Resources
Our Blog
Alternative Remedies
Appointment Requests for Therapy Only
Appointment Requests for Medication Management and Evaluations
Locations
For evaluation and medication management appointment requests please fill out the form below.
Name of person completing the form
*
First Name
Last Name
Patient name
*
First Name
Last Name
Age
*
Please note at this time we are only able to work with individuals 18+
18-25 years old
26-35 years old
36-45 years old
46-55 years old
56-65 years old
66 years and above
Date of Birth
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email address
*
Phone
*
(###)
###
####
Insurance type
*
Horizion Blue Cross Blue Shield
United Health Care
Oxford
Cigna
Aetna
Medicare Red and Blue Card only
Medicare Managed Care (UHC, AETNA)
Other
If your insurance is not listed provide insurance information
Session type
*
Telehealth
In-person (East Brunswick location only)
Telehealth or in-person sessions
Type of Services
Medication Evalutation and Management
Mental Health Therapy
Reason you are seeking to be evaluated or requesting medication management?
*
Provide all days and times of availability for sessions.
*
Current or previous Mental Health/Psychiatric Diagnosis (all) you have been given in the past. Include dates of diagnosis.
*
Indicate N/A or none if you don't have a diagnosis.
List all medication that you take including psychiatric, over the counter, vitamins and food supplements on a regular basis.
*
Indicate N/A or none if you don't take any medications or suppliments.
List all medical diagnosis (past and present)
example: Diabetes, High Blood Pressure etc..
List your Health Care Providers and their phone numbers.
(PCP, current or past prescriber, specialists)
List dates and reasons for psychiatric hospitalizations, IOP/Partial Hospitalitzations or related emergency room visits?
*
indicate N/A if you have not had any hospitalizations
Have you ever been treated as a sex offender, been incarcerated, had legal issues or history of violence?
*
Indicate N/A or none if you don't have a history and if you do please provide details.
Do you have a court order to see a mental health provider?
*
Yes
No
Please list any past or present substance use issues and what drugs you currently or in the past use.
*
Indicate N/A or none if you don't have any substance use history
Do you suffer from an eating disorder?
*
Yes
No
Have you ever heard or seen things that other people do not hear or see and are not sure if they are real?
*
Yes
No
Do you have any special needs? If yes please describe?
*
Indicate N/A or none if you don't have a special need.
How did you hear about us
*
Google search
Insurance search
Psychology Today
Headway
Friend or Family referral
Other
Thank you!
