• Request for Appointment

  • IMPORTANT

    Please fill out this request for an appointment with as much information as possible.The submission process may take upwards of 30 minutes however this process will give us the appropriate information about whether or not we are able to meet your treatment needs. Incomplete forms will not be considered for appointments.

    You will need to submit a photo of your insurance card on this form. Please take a photo of the front and back of your insurance card and have it saved on your computer or phone before starting this form. If we do not have a copy of this card we cannot verify benefits and no appointment will be offered.

    WE ARE NOT IN NETWORK WITH AHCCCS, MEDICARE, TRICARE, WORKERS COMP, OR EAP programs.

    WE ARE NOT IN NETWORK WITH MOST MEDICARE ADVANTAGE PLANS

    The only Healthcare Marketplace plan we are in network with is AmBetter.

    We are Out of Network for all plans purchased on the Healthcare Marketplace other than AmBetter.

    Please note that submission of this form does not guarantee an appointment nor does it constitute a patient-physician relationship.

    We are unable to see anyone under the age of 17.

    Appointments are scheduled on a case by case basis based on Appointment and Physician availability.

    There is currently a wait list for new patients and we are not able to see everyone who requests an appointment.

  • Are you currently experiencing a medical or psychiatric emergency (actively suicidal or immediate danger to self or others) that requires immediate attention?*

  • Any and all life threatening emergencies need to be immediately evaluated at an emergency facility.

    Do not continue this form and please immediately go to the nearest emergency room or dial 911.


    Tucson Community Crisis Line:
    If you are in  immediate crisis, whether it be for you or your loved one, call the Community Wide Crisis line at (520) 622-6000 or 1 (866) 495-6735.

    The National Suicide Prevention Lifeline is a 24-hour, toll-free, confidential suicide prevention hotline available to anyone in suicidal crisis or emotional distress. 1-800-273-TALK (8255).

    Tucson Healthcare Facilities:

    Banner University Medical Center – Emergency Room
    1625 N Campbell Ave, Tucson, AZ 85724
    (520) 694-0111

    Banner University Medical Center (South Campus) – Emergency Room
    2800 E Ajo Way, Tucson, AZ 85713
    (520) 874-2000

    Oro Valley Hospital Behavioral Health
    1551 E Tangerine Rd, Oro Valley, AZ 85755
    (520) 901-6250

    Palo Verde Behavioral Health
    2695 N Craycroft Rd, Tucson, AZ 85712
    (520) 322-2888

    Sonora Behavioral Health
    6050 N Corona Rd, Tucson, AZ 85704
    (520) 469-8700 or 1 (800) 349-0083

    St. Joseph’s Hospital – Emergency Room
    350 N Wilmot Rd, Tucson, AZ 85711
    (520) 873-3884

    St. Mary’s Hospital
    1601 W St Mary’s Rd, Tucson, AZ 85745
    (520) 872-4910

    Veterans Affairs Medical Center – Veterans Only
    3601 S 6th Ave, Tucson, AZ 85713
    (520) 792-1450

  • I understand that submitting a request does not guarantee an appointment nor does it constitute a patient-physician relationship. New appointments are booked on a case by case basis, depending on physician availability, practice limitations, and ability to provide the appropriate level of treatment services.*
  • I understand that any controlled medications (benzodiazepines, stimulants, opioids, hypnotics) previously prescribed by others does not guarantee continued prescriptions of those medications. Furthermore it is our practice wide policy to limit the use of controlled substances.*
  • Do you have a guardian, a conservatorship, or has anyone been legally appointed to care for your medical or psychiatric needs?*
  • Are you currently engaged in, or do you plan to become involved in, criminal or civil litigation?*
  • Did a judge order you to obtain a psychiatric/psychological evaluation or is your appointment request due to the suggestion of an attorney or law firm?*
  • Do you anticipate being involved in any form of legal proceedings?*

  • Please understand that Arizona Psychiatry is a medical practice whose physicians specialize in the diagnosis and treatment of behavioral health disorders.

    Medicolegal matters are often outside the scope of clinical medicine as they require expertise and communications to third parties, or may not involve both the diagnosis and treatment of a particular patient.

    We will likely need to discuss your specific requests in more detail to determine how we can assist you, but in doing so we ask that you not disclose any confidential or legally privileged information.

    Do not finish this form and please call our office for more information.

  • I understand that a credit card must be placed on file in order to schedule an intake appointment.*
  • Is your request related to needing clearance or accommodations due to a mental health condition?*

  • Please understand that Arizona Psychiatry is a medical practice whose physicians specialize in the diagnosis and treatment of behavioral health disorders. Our psychiatrists do not provide evaluations for work clearance, security clearance, generally suitability for work, suitability to own or posses a firearm, or approving return to work due to mental health issues.

    You will need to speak specifically with a forensically trained mental health expert for this type of evaluation.

     

  • Gender*
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Submission
     - -
    2 digit month, 2 digit day, 4 digit year
  • May we email you regarding treatment, scheduling, billing, prescriptions?*
  • May we text message you regarding treatment, scheduling, billing, prescriptions?*
  • Format: (000) 000-0000.
  • May we text message you appointment reminders to this phone number?*
  • May we leave a voicemail for you at this phone number?*
  • Format: (000) 000-0000.
  • Preferred Method of Contact*
  • Marital Status*
  • Employment Status*

  • PLEASE NOTE THAT WE ARE NOT IN NETWORK WITH AHCCCS, MEDICARE, TRICARE, WORKERS COMP, OR EAP.

    IF YOU DO NOT SEE YOUR INSURANCE LISTED PLEASE DO NOT FILL OUT THIS FORM AND CALL OUR OFFICE.
  • Primary Insurance*

  • Self-Insurance election (e.g.  "self-pay", "self-insured", "out-of-pocket", "cash-pay") requires  notification of applicable laws and policies, as well as your explicit  consent. While Arizona Psychiatry is an in-network provider with many  health insurance companies, we do not currently have relationships with  Medicare/Medicaid (AHCCCS) and some other select private insurers. In  these instances, someone may elect to be self-insured (or pay  "out-of-pocket") when either they do not have health insurance coverage,  when the healthcare provider or practice is "out-of-network", or when  patients explicitly do not want their insurance billed - instead  electing to pay out of pocket at the time of service. Generally, someone  who has health insurance coverage is obligated to submit healthcare  claims to the insurer for reimbursement. If you otherwise have insurance  or other types of health coverage, services received as "self-insured"  will not likely be reimbursed by your insurance carrier or applied to  your deductible, and may complicate your relationship with your health  insurance company. You may want to  discuss this and any repercussions with your insurance carrier before  pursuing this option. By signing below, you are simply acknowledging  that you have read this notification. We will speak with you in more  detail about it later and clarify any questions you may have.

  • Insurance Subscriber Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is the insurance subscriber address the same as the home address?
  • Relationship to Insurance Subscriber*
  • Do you have a Secondary Insurance Plan?
  • Secondary Insurance
  • Secondary Insurance Subscriber Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Relationship to Secondary Insurance Subscriber
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  • How were you referred to us?*
  • Do you have a preference of which psychiatrist you want to see?*
  • Are you open to seeing the psychiatrist through a HIPAA compliant video telemedicine platform (Zoom)?*
  • Are you currently on leave from work or school?*
  • Are you currently on FMLA (Family and Medical Leave Act) or planning to use FMLA?*
  • Are you currently on disability for any mental health or substance use related condition?*
  • Are you considering applying for short term disability?*
  • Have you ever been on short term disability or long term disability for psychiatric reasons?*
  • Do you currently have an emotional service animal?*
  • Are you seeking out accommodations or a letter for an emotional service animal?*
  • Why are you seeking treatment?*
  • What your the ideal appointment length? (does not guarantee appointment length)*
  • Are you willing to take medications to address any mental health conditions?*
  • Are you willing to engage in lifestyle changes to improve symptoms? (ex: diet, exercise, meditation)*
  • Do you currently see a psychiatrist or mental health nurse practitioner?*
  • Do you currently see a therapist or counselor?*
  • Would you be willing to pursue therapy/counseling if it was recommended?*
  • Have you received 2 or more COVID-19 vaccinations?
  • Do you have a medical illness that prevents you from getting the COVID-19 vaccination?
  • Have you recovered from a documented COVID-19 infection in the last 3 months?
  • Please check any conditions that you currently have or have previously had*
  • Have you had any type of lab work/blood work done in the last 6 months?*
  • Have you ever been diagnosed with the following conditions:*
  • Are you currently taking any psychotropic or psychiatric medication?*
  • Have you ever taken psychotropic or psychiatric medication?*
  • What medications have you taken in the past?
  • Have you ever been admitted to a psychiatric facility?*
  • How many times have you been admitted to a psychiatric facility?
  • Have you ever been suicidal?*
  • Have you ever attempted suicide?*
  • How many times have you attempted suicide?
  • Have you ever been to drug or alcohol detox?*
  • How many times have you been to drug or alcohol detox?

  • PHQ9

  • Have you ever experienced a significant period of depression?*
  • Have you ever felt down, depressed, or sad for an extended period of time?*
  • Are you currently feeling depressed, or sad more days than not?*
  • Have things ever been so bad that you thought a lot about death or that you would be better off dead?*
  • Have you ever thought about taking your own life?*
  • Have you thought about taking your own life in the last month?*
  • Have you seriously considered ending your life in the last week?*
  • Over the last 2 weeks, how often have you been bothered by any of the following problems?*
    Rows

  • Severity Measure for Panic Disorder

  • Have you ever had multiple instances of an intense rush of anxiety, or what someone might call a “panic attack,” when you suddenly felt very frightened or anxious or suddenly developed a lot of physical symptoms?*

  • Panic attacks are sudden outbursts of anxiety that develop suddenly and increase in intensity within about 10 minutes.

  • During the last 6 months, have you had a panic attack or a sudden rush of intense fear or anxiety?*
  • Was at least 1 panic attack unexpected, as if it came out of the blue?*
  • Did it happen more than once?*
  • Have you ever worried a lot (for at least 1 month) about having another panic attack?*
  • Did you ever change your behavior or do something different (for at least 1 month) because of the attacks?*
  • Think back to your most severe panic attack. Did you experience any of the following symptoms?*
    Rows
  • How distressing do you find these symptoms?*

  • Severity Measure for Social Anxiety Disorder

  • Does being in social situations or being around other people cause you significant distress?*
  • Please answer the questions regarding your interactions and social situations over the past two weeks*
    Rows

  • GAD-7

  • Over the past 6 months have you been feeling anxious and worried for a lot of the time?*
  • Do you have the tendency to worry about things more than normal? OR do people ever tell you that you worry too much?*
  • Over the last 2 weeks, how often have you been bothered by any of the following problems?*
    Rows

  • PCL-C

  • Have you ever experienced or been a victim of a life-threatening or traumatic event (including sexual assault or abuse) that caused intense fear, helplessness, or horror?*
  • Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please reach each carefully and pick the answer that indicates how much you have been bothered by that problem. If this event happened a long time ago, think back to when you felt most stressed about the life experience to answer.*
    Rows

  • MDQ

  • Has there ever been a period of time lasting around 1 week or longer where you were feeling so good, “high,” excited, or “on top of the world” that other people thought you were not your normal self?*
  • Has there ever been a period of time lasting 1 week or longer where you were feeling unusually irritable, angry, or short tempered for most of the day, for at least several days?*
  • Has there ever been a time lasting 1 week or longer where where you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?*
  • Has there ever been a period of time lasting around than 1 week or longer where you slept much less but still felt rested?*
  • Has there ever been a period of time when you were not your usual self and ...*
    Rows
  • Please rate the severity of the following question*
    Rows

  • YBOCS

  • Do you have any unusual or repetitive thoughts that you know are irrational but you simply cannot stop thinking about (for example, being contaminated by germs)?*
  • Do you feel there are certain rituals you have to do, such as cleaning, tap your hand a certain way or do things in sets of threes, which takes up a lot of time in the day?*

  • Obsessions are unwanted ideas, images or impulses that intrude on thinking against your wishes and efforts to resist them. They usually involve themes of harm, risk and danger. Common obsessions are excessive fears of contamination; recurring doubts about danger, extreme concern with order, symmetry, or exactness; fear of losing important things.

    Compulsions are urges that people have to do something to lessen feelings of anxiety or other discomfort. Often they do repetitive, purposeful, intentional behaviors called rituals. The behavior itself may seem appropriate but it becomes a ritual when done to excess. Washing, checking, repeating, straightening, hoarding and many other behaviors can be rituals. Some rituals are mental. For example, thinking or saying things over and over under your breath.

    Please answer each question by selecting the appropriate answer.

  • How much of your time is occupied by obsessive thoughts?*
  • How much do your obsessive thoughts interfere with your work, school, social, or other important role functioning? Is there anything that you don’t do because of them?*
  • How much distress do your obsessive thoughts cause you?*
  • How much of an effort do you make to resist the obsessive thoughts? How often do you try to disregard or turn your attention away from these thoughts as they enter your mind?*
  • How much control do you have over your obsessive thoughts? How successful are you in stopping or diverting your obsessive thinking? Can you dismiss them?*
  • How much time do you spend performing compulsive behaviors? How much longer than most people does it take to complete routine activities because of your rituals? How frequently do you do rituals?*
  • How much do your compulsive behaviors interfere with your work, school, social, or other important role functioning? Is there anything that you don’t do because of the compulsions?*
  • How would you feel if prevented from performing your compulsion(s)? How anxious would you become?*
  • How much of an effort do you make to resist the compulsions?*
  • How strong is the drive to perform the compulsive behavior? How much control do you have over the compulsions?*

  • BPD

  • Do you find that you can be feeling okay then suddenly feel angry, or you can be feeling okay and suddenly feel sad?*
  • Do you think that the usual way that you react to things or behave with people has impacted your close relationships in a negative way?*
  • Do you often have difficulty perceiving and interpreting yourself, other people, and/or events?*
  • Do you get emotional easily, often for very little reason?*
  • Please answer how you agree with each of the following statements:*
    Rows

  • NCI

  • Do you think that people are often jealous of your accomplishments or talents?*
  • Do you find it easy to get people to do what you want?*
  • Do other people ever tell you that you are irresponsible or impulsive?*
  • Please answer whether or not you agree with the following statements*
    Rows

  • Prodromal Questionnaire - 16

  • Have you had any strange or odd experiences lately that you cannot explain?*
  • Do you ever hear things that other people cannot hear, such as noises, or the voices of other people whispering or talking?*
  • Do you ever have visions or see things that other people cannot see?*
  • Do you ever feel that people are bothering you or trying to harm you?*
  • Has it ever seemed like people were talking about you or taking special notice of you?*
  • Have you ever been diagnosed with psychosis?*
  • Please indicate whether or not you agree with the following statements*
    Rows

  • Disordered Eating Measure

  • Have you ever regularly restricted food due to a fear of gaining weight?*
  • Have you ever regularly purged food due to a fear of gaining weight?*
  • Do you regularly eat excessively to the point you felt you had no control over eating?*
  • How much more or less do you feel you worry about your weight and body shape than other people your age?*
  • How afraid are you of gaining 3 pounds?*
  • Compared to other things in your life, how important is your weight to you?*
  • Do you ever feel fat?*
  • During these episodes of eating an unusually large amount of food with a sense of loss of control, do you:*
  • How distressed or upset have you felt about these episodes?*
  • Do you consume a small amount of food (i.e., less than 1200 calories/day) on a regular basis to influence your shape or weight?*
  • When was the last time you went on a diet?*
  • Are you currently in treatment for an eating disorder?*

  • Drug Abuse Screening Tool

  • Have you ever regularly used an illicit drug (cocaine, heroin, methamphetamine, psychedelics, etc) or used a prescription medication for non-medical reasons?*
  • Are you currently using illicit drugs (cocaine, heroin, methamphetamine, psychedelics, etc) or prescription medications for non-medical reasons?*
  • Please check the substances that you have used before*
  • Have you used drugs other than those required for medical reasons?*
  • Do you abuse more than one drug at a time?*
  • Are you always able to stop using drugs when you want to?*
  • Have you had "blackouts" or "flashbacks" as a result of drug use?*
  • Do you ever feel bad or guilty about your drug use?*
  • Does anyone important in your life ever complain about your involvement with drugs?*
  • Have you neglected your family because of your use of drugs?*
  • Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?*
  • Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?*

  • Alcohol Use Disorders Identification Test

  • Have you ever felt that you needed to cut down on drinking alcohol? OR Have you ever felt guilt about your drinking habits?*
  • How often do you have a drink containing alcohol?*
  • How many standard drinks containing alcohol do you have on a typical day when drinking? (12 oz beer, 1.5 oz hard liquor, 5 oz wine)*
  • How often do you have six or more drinks on one occasion?*
  • During the past year, how often have you found that you were not able to stop drinking once you had started?*
  • During the past year, how often have you failed to do what was normally expected of you because of drinking?*
  • During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?*
  • During the past year, how often have you had a feeling of guilt or remorse after drinking?*
  • During the past year, how often have you been unable to remember what happened the night before because you had been drinking?*
  • Have you or someone else been injured as a result of your drinking?*
  • Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?*

  • ASRS

  • Since childhood, is it normal for you to be easily distracted or disorganized?*
  • Since childhood, is it normal for you to often miss important details or made mistakes at work (or school) or while taking care of things at home?*
  • Since childhood, have you often started things and then dropped them without finishing because you lost your focus or got sidetracked?*
  • Please mark the response that most closely represents the frequency of occurrence of each of the symptoms over the past 6 months.*
    Rows

  • PLEASE PRESS SUBMIT TO COMPLETE THE REQUEST

  • Should be Empty: