Consultation Request
Dr. Jennifer Bernstein
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Patient's Name *
Patient's Date of Birth *
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Patient's Gender *
Patient's Phone Number *
Patient's Email Address *
How were you referred to me? *
What kind of treatment is being sought? *
Required
Please describe what brings you to treatment. *
Are you currently in therapy? If yes, with whom? *
Are you currently taking psychiatric medication? If yes, which ones? *
Have you ever received intensive psychiatric services, including hospitalization, partial hospitalization or intensive outpatient treatment? If yes, when and for what reason?
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Do you have a history of suicide attempts or self-injuring? If yes, please elaborate.
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Are there any times that would NOT work for scheduling an appointment?
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Insurance:
Dr. Bernstein does not participate in insurance plans and does not file insurance claims. Contact your insurance carrier directly to verify your out-of-network benefits and to request specific instructions for filing out-of-network claims. You will be provided a statement of service with all the codes necessary to file a claim with your insurance carrier. Dr. Bernstein cannot guarantee insurance reimbursement of any kind.

Fees:
60 min Initial Consultation - $375
45 min Psychotherapy Session - $295
30 min Medication Management Follow-up - $215

I have read the above and understand that I am responsible for payment in full at the time service is rendered.

(Please note: Dr. Bernstein will respond by email within one business day. Please check your spam folder if you have not received a response.)
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