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* Indicates required question
Which psychiatrist do you prefer to see?
Dr Usama Feroze
Dr Ujala Fawad
No preference. Whoever has first opening
Clear selection
I am interested in
*
Diagnosis / medication management
Psychotherapy only. I do not want to take medications
Spravato/Esketamine for treatment resistent depression
Other:
Required
What are your goals for your initial visit
*
Your answer
Have you been diagnosed with any psychiatric illness before?
*
ADHD
Depression
Anxiety
PTSD
Bipolar
Substance Abuse
Schizoaffective Disorder/Schizophrenia
Alcohol use disorder
Other:
Are you currently on psychiatric medications? Please name them:
*
Your answer
How did you hear about us?
Primary Care Provider
Search Engine
Website
Social Media
Friends or Family
Therapist
I have seen Dr. Fawad before
I have seen Dr. Feroze before
Other:
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Legal First name
*
Your answer
Preferred Name
Your answer
Last name
*
Your answer
Birth Date
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MM
/
DD
/
YYYY
Address line 1
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Your answer
Address line 2
Your answer
State
*
Your answer
Zip Code
*
Your answer
Primary Insurance Plan
*
Choose
Blue Cross Blue Shield
United Health Care
Cigna
Aetna
Harvard Pilgrim
Tuft Health Plan
Mass General Brigham/ Allways
MBHP
Medicare A&B
commonwealth Care Alliance
Health plan Inc
Other
Subscriber ID:
*
Your answer
Group #
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Your answer
Subscriber:
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Choose
Self
Parent
Spouse
Other
Subscriber First Name:
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Your answer
Subscriber Last Name:
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Your answer
Subscriber Date of Birth:
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MM
/
DD
/
YYYY
Subscriber Address line 1:
Your answer
Subscriber Address line 2:
Your answer
Subscriber State:
Your answer
Subscriber Zip code:
Your answer
Secondary Insurance
Your answer
email address:
*
Your answer
phone number
*
Your answer
Preferred method of communication
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Email
Phone
Is it ok to leave voice message on your phone?
*
No
YES
Required
What is 5+2
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Your answer
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