Phone Call Request Form

Dr. Elaine Orabona Foster

Prescribing Psychologist
Phone Call Request Form

I am a prescribing and clinical psychologist. I provide short-term (usually 12 weeks) psychotherapy. I can provide medications when necessary. Let's chat a bit before making our first appointment. Getting to know you before scheduling an in person assessment, will help determine if my services are right for you. All answers are confidential.
Name*

First Last
Do you live in Texas or New Mexico?*

Yes I live in New MexicoYes, I live in Texas
Your Contact Number*
Please enter a valid phone number.
Email Address
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What services are you interested in?

VA DBQBenefits Before DischargeSecurity Guard Level IIIOther
Why are you reaching for help at this time? Be as detailed as you can.
What are your goals for contacting me?
Please check any of the following you have experienced in the past six months

Increased appetiteDecreased appetiteTrouble concentratingDifﬁculty sleepingExcessive sleepLow motivationIsolation from othersFatigue/low energyLow self-esteemDepressed moodTearful or crying spellsAnxietyHopelessnessPanicOther
Please check any of these medical conditions that apply to you.

HeadacheHigh blood pressureGastritis or esophagitisHormone-related problemsHead injuryAngina or chest painIrritable bowelChronic painLoss of consciousnessHeart attackBone or joint problemsSeizuresKidney-related issuesChronic fatigueDizzinessFaintnessHeart valve problemsUrinary tract problemsFibromyalgiaNumbness & tinglingShortness of breathDiabetesHepatitisAsthmaArthritisThyroid issuesHIV/AIDSCancer
What else would you like me to know?
Do you currently have a primary care provider?*

NoYes
These are the times I'm available to contact you:
Should be Empty:

Dr. Elaine Orabona Foster

Phone Call Request Form