Schedule a Consultation

Are you a provider or non-provider?*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Non-Provider Information
What is your relationship to the patient?
Please describe your relationship with the patient.
Zip Code
Reason for contacting PAL
Provider Information
Credentials
Provider Description*
Please specify what type of Specialist Physician
Please specify (Other)
Clinic Name*
Clinic Zip Code*
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Patient Zip Code*
Check one or more options that reflect the patient’s gender*

WomanManNon-BinaryTransgenderIntersexTwo-SpiritGender Non-ConformingSomething else
What other gender does the patient identify as?
What sex was originally listed on the patient's birth certificate?*
Is the patient Hispanic or Latino?*

YesNo
Select one or more of the following races.

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite/Caucasian
Does this patient have a tribal affiliation?*

YesNo
Identify the patient's Tribal Affiliation
Is the patient a descendant or enrolled?
Insurance*
Working Diagnosis (if none apply, please check other)*

ADHDAutism Spectrum/PDDDisruptive Behavior d/oPTSDAdjustment DisorderBipolar DisorderEating DisorderSubstance UseAnxietyDepressionManiaPsychosisComorbid MedicalComorbid DevelopmentalOther
If other, please describe.
Current Medication*
Past Medication*
N/A
Other Concerns*

AggressionAttachmentAttention/ConcentrationBehavior at SchoolCompulsivitySelf-InjuryEating ProblemsHallucinationsHyperactivityImpulsivityIrritabilityLegal ProblemsObsessive ThoughtsParent-Child ConflictReckless BehaviorSleep ProblemsSomatic ComplaintsSubstance UseSuicidalityTicsTrauma HistoryTruancy Academic PerformanceOther
If Other, please describe.
Reason for Call.*
Do you already have an appointment scheduled to talk about another patient and would like to add this patient to that appointment?*

YesNo
What date and time is the appointment for your first patient?

MonthDayYear

Hour MinutesAM/PM Option
If you would like to schedule an appointment to discuss more than one patient, please fill out an additional form. There is no need to schedule another appointment. Please reference the appointment date and time on any additional patients' forms. No more than three patients can be discussed within a 15 minute appointment time.
Schedule an appointment for a Psychiatric Consultation. Choose a date and time.*
Should be Empty:

Non-Provider Information

Provider Information

Patient Information