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*

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Yes I live in New MexicoYes, I live in Texas
Your Contact Number*
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Email Address
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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?
Increased appetiteDecreased appetiteTrouble concentratingDifﬁculty sleepingExcessive sleepLow motivationIsolation from othersFatigue/low energyLow self-esteemDepressed moodTearful or crying spellsAnxietyHopelessnessPanicOther
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?
NoYes
These are the times I'm available to contact you:
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Dr. Elaine Orabona Foster