Foresight Appointment Request Form

Request an appointment
Welcome to Foresight!

We're so glad you're here. We're excited to have the opportunity to support you on your path to well-being.

In order to get you scheduled as soon as possible, please complete this form accurately and in its entirety. We will use the information provided to schedule your first appointment directly. You will need your insurance information to complete this form.

By completing the form below, you agree to be automatically booked for your requested appointment services. Please note, you are expected to call us or message us through the secure patient portal at least 48 hours in advance if you need to cancel your appointment. This is to avoid any late cancellation or reschedule fees.

If you have any questions about our services or are unsure how to proceed, please give us a call at 888-588-8995 and we would be happy to assist you and schedule you over the phone.

To ensure that the appropriate individual receives the necessary care, please provide their specific information if you are completing this form on their behalf.
First Name of the individual receiving services*
Last Name of the individual receiving services*
Preferred Name
What are your pronouns?
Email*
example@example.com
Date Of Birth of the individual receiving services*

MonthDayYear
Date
I understand that not all Foresight providers are enrolled with Medicare. I also understand that when I am enrolled, or enroll in the future, with Medicare or a Medicare Advantage Plan, it is my responsibility to report that information to Foresight so that my plan may be verified to determine if services will be covered. Any visits not covered by my insurance plan will be my financial responsibility.
I understand that a copy of any existing custody agreement must be submitted before scheduling can take place. Foresight holds no liability for undisclosed custody agreements
Phone Number*
Please enter a valid phone number.
What is your current gender identity (select one)?*
Sex (as listed on insurance policy)*
Street Address*
City*
State of Residence*
Services are available only in the states shown in the dropdown menu above. Please note: You MUST be in the state you are receiving services for all appointments.
Zip Code*
What type of care are you seeking? (select all that apply)*

Individual TherapyFamily TherapyCouples TherapyPsychiatry/Medication ManagementEAPADHD Testing
What type of care are you seeking? (select all that apply) AZ*

Individual Therapy
What type of care are you seeking? (select all that apply) FL*

Individual TherapyFamily TherapyCouples TherapyPsychiatry/Medication ManagementEAP
What type of care are you seeking? (select all that apply) CA*

Individual TherapyFamily TherapyCouples TherapyPsychiatry/Medication ManagementADHD TestingMaternal Mental HealthEAPDBT Workshop (Virtual)IOP/PHP In-person (Only in Folsom/Berkeley)Virtual IOP
What type of care are you seeking? (select all that apply) GA*

Individual TherapyFamily TherapyPsychiatry/Medication ManagementEAPADHD TestingTMS Consult
What type of care are you seeking? (select all that apply) IL*

Individual TherapyCouples TherapyEAP
What type of care are you seeking? (select all that apply) TX*

Individual TherapyFamily TherapyEAP
Are you trying to conceive, pregnant, or recently postpartum and seeking care from our maternal mental health specialists?*

YesNo
Your journey begins with a 45–60 minute initial assessment with one of our maternal mental health psychiatric specialists. During this appointment, you’ll receive a comprehensive evaluation and personalized treatment plan. Based on your needs, we’ll then match you with the most appropriate provider for ongoing care and support.
Please choose the ONE option that best describes you today*

Currently pregnantPost-partumTrying to conceive / or considering pregnancyNot currently pregnant nor planning pregnancyExperiencing menstrual-cycle-related concerns (e.g., PMDD, PME)Peri- or post-menopausalOther
Baby's birth date*

MonthDayYear
Date
Reason for Seeking Care check any that apply*

Psychiatry (can include evaluation for starting a psychiatric medication, or changing/continuing existing medications, disability initiation or continuation)Individual TherapyFamily/Couples TherapyOther
Transcranial Magnetic Stimulation (TMS) is an evidence-based, FDA-approved, drug-free, noninvasive treatment that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of major depression and other conditions, including OCD and migraines, without side effects of medication.

PLEASE NOTE: All consultations will be held in our Smyrna Office.
Are you (or someone you care for) currently suffering from symptoms of depression? (sadness, low energy, poor concentration, appetite changes, irritability)*

YesNo
Have you (or someone you care for) been diagnosed by a health care professional with depression?*

YesNo
Have you tried, or are you currently on a prescription antidepressant medication?*

YesNo
Which DBT Workshop would you like to join?*

Option 1: Virtual Mondays 5:30p-6:30pOption 2: Virtual Thursdays 1:00p-2:00p
I understand that the DBT Workshop is a 6 week program and am aware that i must attend all 6 sessions
I am aware and agree to the DBT Workshop $40 self-pay fee that will be charged after each workshop attendance
Are you currently experiencing any active psychotic symptoms (i.e., hearing voices, seeing things that aren't there)?

YesNo
Please specify symptoms and length of time experiencing symptoms.
Are you currently utilizing any substances, whether recreational or prescription (i.e. marijuana, alcohol, norcos)?

YesNo
Please specify substances, how much, and how often.
Are you currently experiencing any active manic symptoms (i.e., not sleeping/barely sleeping, racing thoughts, grandiosity)?

YesNo
Please specify symptoms and length of time experiencing symptoms.
Which EAP are you hoping to use?
Please provide the EAP Code/Authorization number
How many units of service (Number of sessions) have been authorized?
EAP Authorization Start Date

MonthDayYear
Date
EAP Authorization End Date

MonthDayYear
Date
At Foresight, we provide outpatient mental healthcare and our therapists are able to support a diverse array of treatment needs, including issues related to anxiety, depression, adjusting to life's challenges, behavioral challenges.

If these specialties/modalities don’t fit your needs, we have providers who do!
What are you looking to focus on at Foresight? (Choose up to three)

Acceptance & Commitment Therapy (ACT)Attention Deficit Hyperactivity Disorder (ADHD)Autism Spectrum DisorderBipolar DisorderBrainspottingChronic Pain or IllnessCognitive Behavioral Therapy (CBT)Dialectical Behavior Therapy (DBT)Eating DisordersEye Movement Desensitization & Reprocessing (EMDR)Harm Reduction SupportInfertility SupportInsomnia & Sleep SupportLGBTQIQ2s+ Mental HealthNon-Substance Addiction SupportNon-Suicidal Self-Injury SupportObsessive Compulsive Disorder (OCD)Parenting SupportPersonality DisordersPregnancy & Postpartum SupportSex TherapySubstance AbuseVeterans/Military Personnel Support
To ensure receiving the best possible care, please list all current medical conditions you are experiencing and your reason for seeking treatment. This information will assist us in matching you with the most suitable provider for your needs. *
If there are no Individually Licensed providers within your insurance network that meet your needs, would you be interested in scheduling with one of our associate therapists?
In order to provide access to high quality mental health care, Foresight is participating in an Associate Therapy program which may have more availability. A Registered Associate Therapist is a fully qualified and registered mental health professional working towards accumulating supervised clinical hours required to practice independently. The supervision of an associate therapist provides an added benefit to the client by ensuring a dual layer of expertise and oversight, enhancing the quality and efficacy of the therapeutic process.
The questions provided aim to confirm Foresight Mental Health as the best fit for your unique needs. Incomplete responses or not fully engaging with these questions could result in a care mismatch, potentially necessitating a referral beyond Foresight. Please note, appointments falling outside our scope or policies will incur charges, underscoring the importance of accurate responses to ensure the highest quality of care for you or your loved one.
I acknowledge that objective ADHD testing is mandatory before initiating or maintaining stimulant treatment. External records must be submitted and approved for continuation. If no prior testing is available, Foresight can conduct an in-house IVA-2 test for a self-pay fee. I understand that I am scheduling a one-hour appointment with a psychiatric provider to evaluate my symptoms and determine whether a referral for ADHD testing is appropriate at this time.
Please note: Any external ADHD testing will be reviewed during your initial evaluation. Please note, we are unable to assess tests prior to this scheduled evaluation.
For external ADHD testing, we only review the following assessments:
- IVA (QS, 1, 2)
- TOVA
- QBTEST
- MOXO CPT
- Conners CPT-3 (computer-administered test, not self-reporting)
All testing is reviewed against validated markers established in studies for each relevant test. Please be aware that our decision to approve testing or recommend additional testing may differ from your previous provider’s interpretation, especially if multiple elements outside the test’s intended metrics contributed to the diagnosis.
Thank you for your cooperation in following these guidelines to ensure a smooth evaluation process
I confirm that I am not currently having active suicidal thoughts with plans or intentions to act on them. I recognize that outpatient psychiatry may not be appropriate for those in such conditions, and a more intensive care level may be recommended during my initial appointment should I choose to schedule.
I acknowledge that the initiation or continuation of medication is not assured, and decisions regarding this will be determined by the provider after a comprehensive assessment of symptoms, either during or following the initial appointment.
I am not seeking Medication-Assisted Treatment (MAT) therapy for opioid use and withdrawal, including but not limited to Suboxone and Methadone.
I verify that I have access to a stable internet connection suitable for video calls and have secured a private space for virtual consultations. Furthermore, I have alternative arrangements, like a mobile device, available for use should my internet connection fail.
I affirm that I currently reside in the state where I am seeking services, and that I will be physically present in the state where the services are being provided at the time of my appointment. I commit to remaining a resident in the state for at least the next 30 days to ensure continuity of care.
I am aware that Foresight Mental Health psychiatry providers do not manage long-term disability cases. They may, however, consider short-term disability for limited durations, with such decisions being at the provider's discretion. Notably, short-term disability is generally not provided on the first visit and depends on the unique details of the case.
To ensure receiving the best possible care, please list all current prescription medications. Over-the-counter medications are not necessary. *
If no current medications, write none.
Would you prefer a provider who identifies as a person of color?

YesNo
Today's Date

MonthDayYear
Date
Age - Years
Name Of Parent Or Guardian*

First NameLast Name
Email Address Of Parent Or Guardian*
example@example.com
Phone Number Of Parent Or Guardian*
Please enter a valid phone number.
Parent Or Guardian date of birth*

MonthDayYear
Date
If available in your area, are you interested in being seen in-person at one of our offices? If there is no in-person availability in your area, you will be booked for virtual sessions.*

YesNoSometimesNo preference
Referring Provider Name
Referring Provider Phone Number
Please enter a valid phone number.
Current Symptoms/Issue
Depressed mood, excessive sleeping, etc..
Please include the name, date of birth, phone number, email address and physical address (if different) for all participants
EAP Benefits Information*
Please include referral number, number of visits etc...
Insurance Provider*
To confirm your share of the cost of care, we recommend you reach out to your insurance provider.
Insurance Provider*
We recommend you contact your insurance provider to confirm co-pays and coverage limits.
Name of Insurance Provider*
Insurance Provider AZ*
To confirm your share of the cost of care, we recommend you reach out to your insurance provider.
Insurance Provider CO*
To confirm your share of the cost of care, we recommend you reach out to your insurance provider.
Insurance Provider FL*
To confirm your share of the cost of care, we recommend you reach out to your insurance provider.
Insurance Provider GA*
To confirm your share of the cost of care, we recommend you reach out to your insurance provider.
Insurance Provider TX*
To confirm your share of the cost of care, we recommend you reach out to your insurance provider.
Insurance Provider IL*
To confirm your share of the cost of care, we recommend you reach out to your insurance provider.
University
Subscriber ID*
Please upload a copy of the front and back of your insurance card here*

Cancelof
I am unable to upload this right now, but understand that this may be required of me before scheduling
Are you the primary subscriber of this insurance policy?*

YesNo
Primary Subscribers Name*

First NameLast Name
Primary Subscribers Date Of Birth*

MonthDayYear
Date
Authorization #*
Authorization Start Date*

MonthDayYear
Date
Authorization End Date*

MonthDayYear
Date

We want to schedule you as quickly and efficiently as possible. Please select ALL times that you are available for weekly appointments.*

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm

If a weekly slot isn't available, are you okay with being scheduled every other week to start? Your therapist will work with you to determine the right care plan.*

YesNo
Is there a particular provider you were hoping to be scheduled with?
Some of our providers may not have availability for new clients, so please note that putting a providers name here does not guarantee you will be scheduled with that provider.
I understand that if my preferred provider is unavailable, i may be scheduled with a similar provider
Please indicate your preference regarding the gender of your provider.*
Consent to SMS Text messaging (By selecting Yes and providing your mobile number, you are agreeing to receive SMS messages from Foresight). Message frequency may vary and Msg&Data rates may apply.*

YesNo
Terms for scheduling Therapy

Due to high demand and limited availability, we will schedule your first therapy session based on information you provide on this form.

Once your intake session is scheduled, we will send you a confirmation email and text (if you’ve opted to receive texts from us).

After your first session, you and your therapist will collaborate to decide if ongoing treatment is right for you, if there are any considerations that would be better supported by another provider or treatment, and if you’d like to schedule any future sessions.
Terms for Scheduling Psychiatry/Medication Management

If you're seeking Psychiatry/Medication Management services, we'll schedule your session based on the information provided on this form. Once your session is booked, we'll send you a confirmation email and give you a call. If you've opted to receive texts from us, you may also receive a confirmation text. Please note that the booked appointment is for a 60-minute psychiatric evaluation. Following your first meeting with your psychiatric provider, you'll collaborate to determine the suitability of ongoing treatment, explore any considerations that may be better addressed by another provider or treatment, and decide on future sessions. Your appointment may be booked with a Doctor or Nurse Practitioner, depending on availability.

A Nurse Practitioner possesses the necessary skills in making diagnoses, conducting medical assessments, and prescribing medications, adhering to their scope of practice. This includes evaluating mental health conditions, developing treatment plans, and providing brief supportive therapy within the psychiatric appointment. It's important to note that medication management is most successful when a patient also has a separate therapist they are working with.

Please also note that we provide outpatient mental healthcare services at Foresight, and if your needs require a higher level of care, your provider will discuss appropriate next steps with you.
Please note the following disclaimers regarding Psychiatry appointments
- Disability requests are at the discretion of the provider and typically only granted after an established relationship has been developed.
- At Foresight, we require testing before the prescribing of any stimulant medications for ADHD. If you have previous in depth neuropsych testing or IVA testing, we can waive this requirement.
  - Please upload your previous testing prior to your appointment to allow your provider to review for sufficiency.
  - If testing is required, the cost is $200 and it is conducted virtually.
- Your initial appointment is an evaluation in which assessment will be conducted and treatment recommendations may or may not be made until a follow up appointment depending on the amount of information needed.
- Medication is not guaranteed to be continued at its same dose or frequency as it is up to the discretion of the provider to make treatment recommendations based on their assessment.
I have read and understand the terms of scheduling my appointment(s).*

YesNo
How did you hear about us?

Insurance referralOnlinePsychology TodayUniversity referralProvider referralCurrent Foresight memberCare SolaceOther Parents Like MeInternet advertisementInternet searchOther
How did you hear about us?
If you’d like to be matched with the provider you found on Psychology Today, please let us know their name *
We’ll do our best to schedule you with that provider, but if availability doesn’t align, we may match you with another clinician
Name of provider?*
I understand that If I have a change of insurance plan while receiving services with a Foresight provider, it is my responsibility to report this change to Foresight so that we may verify that your new plan will continue to cover your services.
If you are having thoughts of harming yourself or someone else to the extent of having means, intent and/or access, and those thoughts are impacting your activities of daily living, please contact 911 or the National Suicide Prevention Lifeline at 988.

We provide outpatient mental healthcare services at Foresight and your needs may require a higher level of care than what we offer.
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