New Patient Request

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 *

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

Yes No

Reason for seeking treatment (choose all that apply) *

Medication Management Medical Marijuana Card (please include your MMCC number below) 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.

MMCC Issued ID Number (if applicable) *

This is the number assigned to you when you apply with the state for a medical marijuana card.

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

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 *

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

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Home
Services
New Patient Request
- New Psychiatric Patient Request
- Cannabis Certification Request
Payments
Simple Practice Sign-In
Contact Us
Search Site
Education

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