New Patient Request

NEW PRIVATE PAY PATIENT REQUEST FORM

* Indicates required field

Legal Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Cell Phone Number *

Is it ok to send you text reminders of appointments, cancellations and/or paperwork that is due? *

Yes No

Date of Birth *

Gender *

Time Zone *

MMCC ID #, if requesting certification for a medical marijuana card *

PRIVATE PAY RATES

Private Pay Initial Psychiatric evaluations (40 minutes) = $350
Private Pay Medication Checks (20 minutes) = $150
Comprehensive Written Psychiatric/Psychosocial Evaluation for a 3rd Party = $400
No Shows or Cancellations within 48hrs of the appointment: $25

*Other fees may apply and are indicated on the informed consent

This request is not an emergency or urgent matter - I wish to proceed *

Yes

After you have been approved for services, you will receive an email with a link to set up your Headway account. Headway is used for billing purposes, contacting your provider and scheduling follow up appointments. Once you have completed your Headway account set up and your Health History Form you can schedule your first appointment via the link below.

*This information will be sent to a non-HIPAA compliant email. Please note this is not a secure means of communication so your confidentially cannot be ensured.

Submit

HEALTH HISTORY FORM

Appointment Scheduling Link