Psychiatric Consultation Request

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Dr. Alisha Jaquith is a Child, Adolescent and Adult Psychiatrist in solo private practice. She practices in Millbury, MA and offers both telehealth and in person appointments. Dr Jaquith accepts BCBS insurance or private pay.

If you are interested in scheduling an assessment to see if you are a good fit for her practice, please fill out the below information.

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 or crisis center.

Email *

Today's Date *

YYYY

Patient Name (First and Last) *

Date of Birth *

YYYY

Patient gender *

Female

Male

Transgender (male to female)

Transgender (female to male)

Gender Fluid

Other:

Relationship to the patient *

Myself

Parent/Guardian

Other:

Parent/Guardian Name (First and Last). Write NA is not applicable. *

Phone Number *

Home Address *

How were you referred to me? *

What are the main concerns? Check all that apply: *

Anger

Anxiety

Attentional difficulties

Autism Spectrum Concerns

Behavioral problems

Bipolar Disorder

Defiance/oppositionality

Depression

Eating/body image concerns

Educational difficulties

Moodiness/Irritability

OCD

Psychosis

Substance Abuse/Dependence

Other:

Required

Check all of the following that are applicable: *

In therapy now

In therapy in the past

On psychiatric medication now

Taken psychiatric medication in the past

In the hospital now or recently

Hospitalized for psychiatric reasons in the past

Attempted suicide in the past

Known neurological or genetic disorder

Currently using substances including alcohol or drugs

Past problems with alcohol or drug abuse

Current or past treatment for substance abuse

None of the above

Required

What kind of care if being sought? *

Medication assessment and management

Therapy only

Medication management and therapy together

Not sure

Other:

If the patient is currently on medication, please list current medications: *

Scheduling Information

Dr. Jaquith works Monday through Thursday and has limited after school appointments. Most individuals will need to be seen between 8am and 2pm. Please fill out the scheduling information below so we can assess how to best manage scheduling appointments.

Are you interested in telehealth or in person appointments? *

In person

Telehealth

I don't know

Other:

Are you able to attend appointments Mondays through Thursday between 8am-2pm? I do not offer evening or weekend hours. *

Yes

Other:

Do you have other scheduling limitations?

Payment Information

Dr. Jaquith takes BCBS insurance or private payment. She does not take any other insurance other than BCBS.

What will the payment method? *

Blue Cross Blue Shield

Private Pay

If you plan to use insurance, what is the policy ID number? For private pay, enter "NA" *

This space is for any additional information that you would like to share:

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