INFORMATION REQUEST QUESTIONNAIRE
Labyrinth Psychiatry Group is happy to help guide you toward your most appropriate treatment option depending upon your current symptoms, treatment history and personal preferences. Please fill out the form below so we can reach out and help provide you with more information regarding potential treatment options*.
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
E-mail
Zip Code
How would you like to be contacted?
Phone
Email
Facebook Messenger
Current Insurance
Medicare
Commercial Insurance
None. I plan to pay myself
Have you ever been diagnosed with depression by a mental health professional or primary care physician?
Yes
No
Have you ever tried psychotherapy?
Yes
No
How many psychiatric medications have you tried?
0
1
2
3+
Are you interested in more information about treatment options for depression?
Yes
No
Would you prefer a telehealth or "in-office" evaluation?
Telehealth
In-office
*This information is not being collected by a marketing firm and will not be shared with any third parties. Labyrinth Psychiatry Group is compliant with HIPAA regulations. You may contact our office at (908) 336-1187 to learn about our privacy policy and how we collect, keep and process your private information in accordance with these laws.
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