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Consultation Request with Dr. Fink
Dr. Fink is currently accepting new patients, and we can usually schedule initial consultations within 2-3 weeks of patient registration.
* Indicates required question
Email
*
Your email
Clinical Info
Please tell us about the person for whom treatment is being requested
Patient first name
*
Your answer
Patient last name
*
Your answer
Patient/client gender
*
Choose
Female
Male
Agender
Androgyne
Adryogynous
Bigender
Cis
Cisgender
Cis Female
Cis Male
Cis Man
Cis Woman
Cisgender Female
Cisgender Male
Cisgender Man
Cisgender Woman
Female to Male
FTM
Gender Fluid
Gender Noncomforming
Gender Questioning
Gender Variant
Genderqueer
Intersex
Male to Female
MTF
Neither
Neutrois
Non-binary
Other
Pangender
Trans
Trans*
Trans Female
Trans* Female
Trans Male
Trans* Male
Trans* Man
Trans Person
Trans* Person
Trans Woman
Trans* Woman
Transfeminine
Transgender
Transgender Person
Transgender Woman
Transmasculine
Transsexual
Transsexual Female
Transsexual Male
Transsexual Man
Transsexual Person
Transsexual Woman
Two-spirit
Patient's Date of birth
*
MM
/
DD
/
YYYY
My relationship to the patient
*
Myself
Father
Mother
Legal Guardian
Other:
Required
My phone number
*
Your answer
How were you referred to me?
*
Your answer
What are the main issues? Check all that apply:
*
Anxiety or Stress
Attentional Difficulties
Bipolar Disorder
Behavioral Problems
Depression/mood
Eating/body image issues
Grief
Hallucinations, Paranoia, Unusual Thoughts
Trauma
Substance Use
Relationship or Family Issues
Other:
Required
Check all of the following that are applicable:
*
In therapy now
On psychiatric medication now
In the hospital now or recently
In therapy in the past
Taken psychiatric medication in the past
Attempted suicide in the past
Hospitalized for psychiatric reasons in the past
Known neurologic or genetic disorder
None of the above
Other:
Required
What kind of care is being sought?
*
Evaluation / Diagnostic Clarity
Medication
Psychotherapy
Not sure
Other:
Required
After you submit your request, you will get a call or email response within 1-2 business days with further instructions. Thank you!
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