Consultation Request
Jasmine Sawhne, MD MBA
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This form helps prospective patients/clients and clinicians connect more efficiently and explore whether the requested relationship will be a good fit. As clinician skill sets, availability, and financial policies vary, this form helps ensure you find the right clinician for your needs.

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.


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Patient's Name
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Patient's Date of Birth
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Patient's Gender
Patient's Phone Number
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Patient's Email Address
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How were you referred to me?
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Please describe what brings you to treatment.
What kind of treatment is being sought?
Are you currently in therapy? If yes, with whom?
Are you currently taking psychiatric medication? If yes, which ones?
Are there any times that would NOT work for scheduling an appointment?

Jasmine Sawhne, MD does not participate in insurance plans. I understand I am responsible for payment in full at the time service is rendered, unless other arrangements have been made. I will be provided a statement so I may try to get some reimbursement from my insurance company if I am eligible. *
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