Amodeus Health Care/Dr. Tai Slyne - Prescreening Form
I am a dual board-certified Family Psychiatric Mental Health Nurse Practitioner, Family Nurse Practitioner, and a Doctor of Nursing Practice who specializes in the evaluation and treatment of various mental health disorders across the life span, including ADHD, Anxiety, Depression, Bipolar, Schizophrenia, substance abuse, oppositional defiant disorder, and antisocial personality. I collaborate with other clinicians. My approach is Patient-Centered and Comprehensive. I will take the time to get to know you and understand your specific concerns and goals.
I am interested in caring for young adults to geriatrics. I assist with Benzodiazepine tapering to live a full life without issues of addiction. I have additional expertise in working with adolescents and adults as they cope with academics and peer pressure through college. I also help explore modalities of treating pain in the elderly.
I work on creating a calm and comfortable atmosphere by creating a therapeutic alliance to help you feel comfortable sharing your concerns and needs as we move toward the recovery phase. Together, we will create a treatment plan specific to your needs.

When sending us messages or emails, please choose/cc Beverly Concepcion (bf_concepcion@amodeushealthcare.com) along with me for a quick response. 

Treatment Focus
  • Affective disorders
  • Alzheimer's
  • Anxiety/anxiety attacks
  • Bipolar Disorder
  • Depression
  • Medication Assisted Therapy: Suboxone and Vivitrol

Modality of Consultation:  Office visit / Telehealth / Phone 

Clinic Address: 75 Gilcreast Rd, Suite 210, Londonderry 03053
Phone: (603) 305-7076 
Fax: 1-888-271-7687

Email *

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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Clinical Info
Please tell us about the person for whom treatment is being requested.
Patient's Name:
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Date of Birth: *
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Phone Number: *
Present Home Address:
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How were you referred to me?
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What are the main issues? Check all that apply.
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Check all of the following that are applicable: 
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What kind of care is being sought?
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List the name of medications you are currently taking.
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Name of your Primary Care Doctor, Phone & Fax Number
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Name of your Therapist, Phone & Fax Number
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Emergency Contact Person & Phone Number
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Scheduling Info
Are there any times that would NOT work for scheduling an appointment?
List any scheduling limitations that you have. 
Specify the day/date that would not work for you. 
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Do you prefer a morning or evening appointment?
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Payment Info
What will be the primary payment method?
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This is for Well Sense & Unicare State Indemnity Plan insured patients only. Dr. Tai's certification is still in process. Are you willing to wait or willing to pay out of pocket for now? 
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If your insurance plan is accepted by the clinician, what is the policy ID number? For self/private pay, enter 'n/a'.
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Is Tai Slyne (Amodeus Healthcare) IN NETWORK under your insurance plan?
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How much is your COPAY for mental health?
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Have you met your DEDUCTIBLE? If not, Please call and verify this with your insurance company prior to making your initial appointment.
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Full upfront payment is required if the deductible is not met and co-pays/coinsurance are expected to be paid at the time of the appointment. Is this okay with you?
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Do you have a SECONDARY INSURANCE? If yes, enter your insurance company & member ID number. Type N/A if none.
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Once accepted, the declared patient's email address and phone number in this form will be used for communication and will be linked to the patient's portal account with Dr. Slyne/Amodeus Healthcare in Osmind. *
Please submit a clear copy/photos of your insurance card/s to bf_concepcion@amodeushealthcare.com after submitting this form.
Submitting a copy of your insurance card will help us expedite verifying your plan benefits, pharmacy details and payer details. 
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