Consultation Request

  • Consultation Request

    This form helps prospective new patients and clinicians connect more efficiently and explore whether the requested relationship will be a good fit. Please complete the following form with a good phone number. Someone from the office will be in touch within 72 hours of the consultation request to discuss goodness of fit and next steps for scheduling.If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this service. Instead call 911 or go to your closest emergency room.

  • Clinical Information

    Please tell us about the person for whom treatment is being requested.
  • Format: (000) 000-0000.
  • I understand I must be physically located in the state of North Carolina for appointments (conducted either in person in Raleigh, NC or virtually located in the state of NC).*
  • I agree to communication with Reset by email and/or phone/text.*

  • Patient Symptoms

  • What are the main issues? Check all that apply:*
  • Check all of the following that are applicable:*
  • What kind of care is being sought?*
  • Have you ever seen a psychiatrist or therapist?*
  • Have you ever been psychiatrically hospitalized?*
  • Have you ever had a suicide attempt or self harmed?*
  • Have you ever struggled with violence or thoughts of harming someone else?*
  • Have you ever struggled with substance abuse?*

  • Have you had any trouble in the past week with any of the following?

    • Pain, fever, chills, weight change
    • Dizziness, headache, lightheadedness, tremor, seizures
    • Vision change, trouble swallowing, dry mouth
    • Chest pain, heart palpitations, passing out
    • Shortness of breath, cough
    • Abdominal pain, constipation, diarrhea, nausea, vomiting
    • Menstrual cycle irregularities, hair loss
    • Anemia
    • Urinary incontinence
    • Muscle pain, stiff muscles
    • Rash

  • Social History

  • Scheduling Information

  • Payment Information

    Elizabeth Cox, MD does not participate in insurance plans.
  • I understand I am responsible for payment in full at the time service is rendered, unless other arrangements have been made. I will be provided a statement so I may try to get some reimbursement from my insurance company if I am eligible. I understand that Dr Cox is opted out of Medicare and I will not be eligible for reimbursement if I have Medicare insurance.
  • Should be Empty: