New patient inquiry
Please fill out this form to the best of your ability. Please be aware that there are times I cannot accept prospective patients based on the type of help they are seeking, their presenting issue, or type of insurance coverage they have. Due to the volume of new patient requests I receive, I am not able to respond to all new patient requests, so if you have not heard back from me within 5 days it is safe to assume I am unable to accept you as a patient. At this time I do not have a wait list.
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Email *
Full Name *
Date of Birth *
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Cell phone number *
Home address
Payment type (currently BCBS is only insurance accepted) *
If you are planning to use insurance, I encourage you to contact your insurance customer service and be sure you understand you benefits including copays, deductibles and limits on services. *Not all BCBS plans use BCBS for behavioral health. Please make sure yours does if you are hoping to use that insurance for our visits.
Expected insurance co-pay (if known)
Briefly describe what you're needing help with: *
Please list any current psychiatric medications or other mental health treatments:
If you were referred to me, please give the name of the person who referred you and their contact information (phone or Email):
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