Consultation Request

Patient Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Patient Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Phone # *

Mobile phone preferred

(###)

###

####

Responsible Party Name *

First Name

Last Name

Phone # *

(###)

###

####

Billing Policy *

I understand that Rethink Psychiatry does not accept any form of insurance, that I will pay out-of-pocket at the time of service, and submit a detailed receipt to my insurance company for reimbursement afterward.

What are your primary interests?

Check any that apply

Better medication management

Reducing or eliminating psychiatric medications

Non-pharmaceutical interventions for psychiatric conditions

Address underlying causes of my condition

Help with diet & lifestyle change

Have you recently had/ are you now having suicidal thoughts? *

Within the last year

Currently

Neither

Have you thought/ are you thinking about hurting anyone else? *

Within the last year

Currently

Neither

Which if any health professional(s) are you currently seeing? *

Psychiatrist

Psychologist

Social Worker

Primary Care

Integrative Medicine Provider

None

Other

Best day(s) of the week *

Telemed is available, but in-person is preferred. Check all that apply

Monday (video)

Tuesday (in-person, video)

Wednesday (in-person, video)

Thursday (in-person, video)

Friday (video)

Saturday (in-person, video)

Best time(s) of day *

Check all that apply

9am – 12pm

12pm – 3pm

3pm – 5pm

Location of appointment *

We prefer all therapy, including consultations, to be in-person, but can accommodate video as well.

Video

In-Person

Either