AMY GRAMMAS, RN, MS, MSN, CRNP-PMH
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NEW PATIENT REQUEST FORM
*
Indicates required field
Legal Name
*
First
Last
I am 18 years of age or older
*
Yes
I only provide services to those 18 years or older
Email
*
Cell Phone Number
*
You can contact me with reminders via (choose all that apply)
*
Email
Text
Voicemail
This request is not an emergency or urgent matter - I wish to proceed
*
Yes
IF YOU DIDN'T ANSWER YES, PLEASE STOP COMPLETING THIS FORM AND EITHER CALL 911 OR REPORT TO YOUR NEAREST EMERGENCY ROOM
Reason for seeking treatment
*
Medication Management
Medical Marijuana Card
Psychiatric Evaluation for 3rd Party
I am new to treatment and would like to explore my options
Please note that I do not provide psychotherapy.
Are you interested in only being evaluation for a medical marijuana card (this is private pay only)?
*
Yes
No
I am a resident of Maryland
*
Yes
I am only licensed to treat patients who reside in Maryland
Do you have a guardian of person or property?
*
No
Yes, I have a guardian of property
Yes, I have a guardian of person
Yes, I have a guardian of property and person
Payment Option
*
Private Pay
Blue Cross Blue Shield
Cigna
United Healthcare
How did you find me?
*
Internet Search
Psychology Today
Referred
Other
I understand 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.
*
Yes
After you have been approved for services, you will receive an email with a link to the Simple Practice Healthcare Portal and instructions with how to schedule your first appointment.
Submit
Home
Services
New Patient Request
Payments
Simple Practice Sign-In
Contact Us
Search Site
Education
Medicinal Cannabis
Why Choose Self-Pay
Education on Psychiatric Disorders
General Education of Psychotropic Medications
Community Resources
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