SNS Appointment Request Form

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Professional Services Inquiry Questionnaire

Email *

Attention: Please, read before proceeding

None of the providers with Shoreline Neuropsychiatric Services participate with Medicaid/Husky or Medicare Insurance. Even if you intend to pay out of pocket, we are unable to accept Medicare or Medicaid enrollees.

Who is the request for? *

Your name. *

Your phone number (123) 456-7890 *

Potential patient's full name (Last, First, MI). *

Potential patient's date of birth (mm/dd/yyyy) *

Potential patient's email *

Potential patient's phone (123) 456-7890 *

Potential patient's address (# street, city, ZIP) *

How did you find Shoreline Neuropsychiatric Services?

Web search

Friend

Another mental health professional

My insurance provider or EAP

Psychology Today or another website

A current or former patient of Shoreline Neuropsychiatric Services

Other:

Clear selection

Which of the following best describes how you intend to pay for services received?

Aetna Insurance

Anthem Blue Cross / Blue Shield Insurance

Cigna Insurance

Optum / United Health (not Medicare) / Magellan Insurance

Connecticare (provided through Optum)

Self pay (out of pocket)

Clear selection

What is your scheduling flexibility?

Considerable flexibility and can be available most of the time

Limited flexibility and I have reviewed the posted hours and can be available at those times

Very little scheduling flexibility

Clear selection

Please, tell us the days and times of likeliest availability.

What services are being requested?

Psychopharmacology (aka Medication Management)

Counseling / Psychotherapy (CBT, Mindfulness)

EMDR Therapy

I would be willing to have some of these services provided by a capable and experienced student/intern, under licensed supervision?

Yes

Maybe

Clear selection

Submit

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