Psychiatric Appointment Request

Name *

First Name

Last Name

Phone (if ok to leave message)

(###)

###

####

Insurance Information *

Please select from our list of in-network insurance options. We provide claim forms upon request for out of network clients to submit to their insurance company after payment.

Anthem or Blue Cross Blue Shield

Community Health Options

Harvard Pilgrim

United Behavioral Health

Out of Network ($575 Evaluation)

Medicare (we are not in network for Medicare)

Have you ever been admitted to a higher level of care? *

NO

YES- Residential Treatment

YES- Inpatient Psychiatric Hospitalization

YES- Partial Hospitalization Program

YES- Intensive Outpatient Program

Are you seeking an evaluation for legal matters?

Yes

No

Are you seeking a provider who is willing to prescribe controlled substances?

Yes

No

Have you ever been in treatment for an alcohol problem? *

YES

NO

How many times in the past year have you used a recreational drug or used a prescription medication for non-medical reasons? *

Almost daily (4+ times per week)

Often (2-3 times per week)

Sometimes (1-2 times per week)

Rarely (1-2 times per month)

Never

How many times in the past year have you used marijuana? *

Almost daily (4+ times per week)

Often (3-4 times per week)

Sometimes (2-3 per week)

Rarely (1-2 times per month)

Never

Do you prefer telehealth or in-person at our Portland office? *

Telehealth

In person Portland office

No preference

Referral Source *

Please let us know how you learned about our office.

I'm a current PSM client

I'm a former PSM client

Psychology Today

Website

Family or friend

Colleague

Primary Care Physician

Another therapist