Fayetteville Psychiatry Waitlist New Patient Appointment Request

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Please complete and submit this form. Once a new patient spot is available, the doctors will discuss your treatment and Julie (Office Manager) will get back to you to schedule an intake appointment. Intake appointments are roughly one and a half hours in length and are $400. We will file insurance on your behalf if you have Blue Cross or Ambetter insurance.
Please call or text us at 479-422-5163 if you have any questions!

Please be aware that Fayetteville Psychiatry has strict and evidence-based policies regarding controlled and potentially addictive medications (stimulants, benzodiazepines, etc). We do not prescribe medical marijuana. If you have any questions or concerns, please ask Julie prior to booking your intake appointment.

Also, at this time, we are unable to offer after-hours care for emergencies If you have a history of multiple psychiatric hospitalizations or suicide attempts, we cannot adequately meet your treatment needs. However, we can certainly refer you to more appropriate treatments.

Please list your name *

Please list your email *

CAN WE EMAIL YOU TO GET YOU SCHEDULED? *

YES

Please list your phone number *

Please list your date of birth *

YYYY

Which insurance company should we bill for you? (If no insurance, or not one of these, you will be considered self-pay *

Blue Cross Blue Shield (not BCBS Federal)

Ambetter

Self-Pay

Which doctor would you like to schedule an appointment with? *

First available

Dr. Nicholas

Dr. Stacey

Dr. Meeks

looking for a therapist appointment, not a prescriber

WHY would you like to make an appointment at Fayetteville Psychiatry? *

Have you been diagnosed with any mental health conditions in the past? If yes, please explain. *

Do you have a psychiatrist? If so, is this for a second opinion? Please describe.

Do you have any specific medication requests that you would like to discuss during your intake appointment?

Have you been hospitalized for a psychiatric reason in the last three years? If yes, please explain. *

Please list your current medications and dosage. *

Please list any medical illnesses for which you are currently being treated. *

Do you currently have a therapist that you see on a regular basis? *

Yes

Other:

List any history of suicide attempts. *

Are you currently having suicidal thoughts? If so, please call the Suicide Hotline at 1-800-273-8255 *

Yes

I understand that scheduling an appointment at Fayetteville Psychiatry requires a $150 non-refundable deposit. *

Yes

Other:

Is there anything else you would like us to know about you?

Submit

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