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Consultation Request Form
Yin S. LI, MD, PhD
YSL Psychiatry LLC
484-489-3511
drli@yslpsychiatry.com
www.yslpsychiatry.com
**If you are experiencing a medical or psychiatric emergency, please call 911 or go to your nearest emergency room.**
**This is a HIPAA-compliant form. All information is strictly confidential.**
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Email
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Your email
DEMOGRAPHIC INFORMATION
Patient Name (First Last)
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Your answer
Patient Age
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Your answer
Patient Date of Birth
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MM
/
DD
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YYYY
Patient Address (Street, City, State, Zip)
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Your answer
Your relationship to patient
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I am the patient
Other:
Best Callback Number
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Your answer
CLINICAL INFORMATION
How were you referred to me?
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Your answer
Please explain why you are seeking help at this time:
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Your answer
What kind of care are you looking for?
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Medication only
Talk therapy only
Both
Not sure
What medications are you currently prescribed? (Include dosage)
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Your answer
Who is currently prescribing your medications?
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Your answer
What medications have you taken before? Were any effective?
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Your answer
Who is your current therapist?
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Your answer
Have you ever had a psychiatric hospitalization? If yes, please describe reasons for hospitalizations.
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Your answer
Do you have a history of significant substance use (e.g., difficulty controlling your use of substances or past treatment for substance use)?
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Your answer
SCHEDULING INFORMATION
Are there any times that would NOT work for scheduling an appointment?
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Your answer
Do you have any other scheduling limitations?
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Your answer
Please list specific times in the upcoming 5 business days that would work for me to call you
Your answer
ABOUT THIS PRACTICE
Dr. Li is conducting primarily telehealth appointments at this time. Would that work for you?
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Yes
No
Dr. Li is only licensed to practice in Pennsylvania. You must be physically located in Pennsylvania during every appointment, even though you are being seen over the Internet. Will that work for you?
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Yes
No
Dr. Li does not participate in insurance plans. He can provide you with a statement to send to your insurance carrier for out-of-network reimbursement. Would that work for you?
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Yes
No
Dr. Li's fee structure is currently as follows: $490 for initial intake, $265 for talk therapy appointments, and $190 for medication management appointments. Would that work for you?
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Yes
No
Dr. Li has limited availability and primarily sees patients on Fridays 9am-4pm. Would that work for you?
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Yes
No
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