REQUEST AN APPOINTMENT

1

Name* This field is required.

First Name

Last Name

2

I confirm that I am age 18 or older:* This field is required.

3

Please confirm State of Residency:* This field is required.

4

Phone Number:* This field is required.

5

Email Address:* This field is required.

6

Please list the Mental Health problem(s) which you are seeking help for:* This field is required.

7

Please list all current Psychiatric Medications. If not applicable, please type "N/A" in the answer box.* This field is required.

8

Are you currently taking or seeking any controlled medications (Ie: Adderall, Xanax)?* This field is required.

Yes

No

I am not sure

9

Please list any controlled medications you are currently taking or seeking. If not applicable, please type "N/A" in the answer box.* This field is required.

10

Prior Psychiatric Hospitalization:* This field is required.

Yes

No

I prefer not to answer

11

Do you smoke cigarettes?* This field is required.

Yes

No

12

Are you interested in exploring lifestyle interventions, such as stress reduction, nutrition, and exercise?* This field is required.

Yes

No

I am not sure

13

What is your current Insurance Carrier (Ie: BCBS, United, Aetna, etc.)? If you do not plan on using insurance, please type "cash pay" in the answer box.* This field is required.

14

I understand that Entera Mental Wellness is primarily a telemedicine service.* This field is required.

Yes

No

I am not sure

15

I understand that Entera Mental Wellness does not offer Individual Counseling at this time. I understand that my nurse practitioner will offer emotional support and applicable therapeutic techniques in the context of our medication management appointments. I understand that if I require more than this, I will be additionally referred to a licensed therapist.* This field is required.

Yes

No

I am not sure

16

Any additional information about yourself or about what you are seeking that you would like us to know:

17

Date