1. Initial Request

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1. Initial Request

Thank you for filling out this initial request for prospective patients.

Email *

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.

This request is not an emergency or urgent matter. I wish to proceed.

Name of patient *

Name of requestor, if not the patient (eg parent)

Patient's age

Contact phone number

Please describe what it is you're hoping to get help with *

Please check all of the following that is applicable

Currently on psychiatric medication

Currently in therapy

Past psychiatric medication

Past therapy

Currently in the hospital / recently discharged

Past hospitalization for mental health reasons

Past suicide attempts

New to mental health care overall

How were you referred to me? If you were referred by a specific person, feel free to tell me who it is in the blank field below (Other...)

Therapist

Another psychiatrist

Psychology Today

Google searching

School

Another patient/ client

Other:

I offer in person and virtual visits. Generally, I recommend the initial intake appointment be in person, and the follow ups can be a combination of in person/ virtual based on your preference. Do you have any preferences?

I am considered "out of network," which means insurance cannot be used. Instead, I can provide you a "superbill," which is a medical receipt that includes diagnostic codes, billing codes, and confirmation of payment. You are then able to submit this to your insurance, who will reimburse you some amount based on your plan.

Please note everyone's insurance plans will have different "out of network" benefits, ranging from none to a substantial amount of reimbursement coverage. If you plan to use "out of network" benefits, consider confirming what they are with your insurance.

If you do not want/ need a "superbill," you will be considered cash only, in which case a Good Faith Estimate will be provided for you after our first appointment.

Which method would you prefer? (You can switch later if needed)

I plan to submit a superbill to my insurance for "out of network" reimbursement.

I plan to be cash only and will need a Good Faith Estimate

Payment via credit card will be via a company called Ivy Pay (no extra cost to you). Once we've set up an appointment on the phone or email, you will receive a text message link to enter a credit card on file on the HIPAA compliant platform. If you prefer non credit card methods, Zelle or other means can be arranged. What would you prefer?

Credit card via Ivy Pay is fine

Zelle

Other:

Clear selection

Do you have MediCare or Medi-Cal? Please note, at this point I am unable to accept MediCare / Medi-Cal patients, even if you want to pay privately, due to the laws around Medicare enrolled providers. This may change in the future. *

Yes

Is there anything else you'd like to share or ask? If not, ok to skip.

Thank you for taking the time to fill this out. I will do my best to call you in 1-2 business days for an introduction, answer any questions you might have, and then schedule. It is ok to text me at 626-888-1224. Is it ok for me to text you at the number you entered above? *

Send me a copy of my responses.

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