Atlanta Telehealth Request for Services Form

REQUEST FOR SERVICES
Patient Name*

First NameMiddle NameLast Name
Patient Location (State)*
Is This Patient Considered Urgent?

Must be seen in 24 hoursMust be seen in 7 daysNot urgent
Patient Birth Date*

MonthDayYear
Veteran's ICN Number **
Example: 1000000000V000000
Gender Identity*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have the patients email address?*

YesNo
If the answer is 'No', please confirm that Atlanta Telehealth will obtain the patient's email address when contacting the patient via phone*

YesNo
Patient E-Mail Address
Patient Phone Number*

Area CodePhone Number
Authorization Number*
Authorization Start Date:*

MonthDayYear
Date
Authorization End Date:*

MonthDayYear
Date
What is the Provisional Diagnosis?*
Authorization Type*

Washington (Individual Therapy)Texas (Individual Therapy)Washington (Psychiatry)Arizona (Psychiatry)Montana (Psychiatry)
Appointment Type (We do not offer in person meetings)*

Video ConferencePhone Call
In the past four weeks has the patient had thoughts of suicidal ideation, self harm or an attempt? **

Suicidal IdeationSuicidal Ideation without self harmSuicidal Ideation and AttemptNot Applicable
In the past four weeks has the patient experienced audio or visual hallucinations?*

VisualAudioAudio and VisualNot Applicable
Therapist Preference*

Female Presenting TherapistMale Presenting TherapistNo Preference
What is the patients availability? *
Schedulers contact information *
Example: test@gmail.com
How Would You Like To Be Notified About The status of the patients appointment? (Please indicate fax, phone, email)
example: phone 111-111-1111 *
Do You Utilize The HSRM System To Upload Documents?*

YesNo
If you do not use the HSRM System please send documents, authorizations or referrals to the email addresses indicated below so we know where to look for the patients information.
- admin@healthbyinvictus.com
  OR
- erica@healthbyinvictus.com
If you encounter any problems while trying to submit the form, or if you notice any issues with its functionality, please do not hesitate to reach out to
- michaeldeligero@healthbyinvictus.com
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REQUEST FOR SERVICES