New Patient Inquiry

New Patient Inquiry

If this is a mental health emergency or crisis, stop and call 911, the crisis line or 988, or go to the nearest emergency department.
We are accepting new patients on a case-by-case basis and need the following information to ensure that we can be a good fit for you and meet your mental health needs.
What's your Full Name?*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Legal Address*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Assigned sex at birth*

MaleFemale
What are your preferred pronouns?

She/Her/HersHe/Hims/HisThey/Them/TheirsOther
What mental health concerns are you seeking help for?*

Help with AnxietyHelp with DepressionHelp with ADHDHelp with Bipolar DisorderHelp with PTSDHelp with OCDHelp with InsomniaHelp with Addiction (Substance, Behaviors, etc.)I'm not really sureOther
What services are you seeking for?*

Medication managementTalk therapy or counselingMedical Weight lossNutritional PsychiatryPharmacogenetic testingI'm not really sureOther
We DO NOT provide the following services: FMLA, Labor & Industries assessments (L&I), Court-ordered treatments, Disability evaluations, Assessments for child custody, work, weapon ownership, child custody, or emotional support animals, Case management, Group, couple, or family therapy, Transcranial magnetic stimulation (TMS), Electroconvulsive therapy (ECT), Intensive outpatient chemical dependency treatment, Forensic evaluations.
What medication(s) are you currently taking?*
Please include dose and frequency. Type "None" if you are not taking any medications currently.
What psychotropic medication(s) have you tried in the past? *
Type "None" if you haven't tried any psychotropic medication in the past or "I forgot" if you can't recall or remember.
What health insurance do you have?*

AetnaCignaFirst ChoiceKaiser PPO (Not Medicare)Premera Blue Cross / Lifewise / AnthemRegence / Blue ShieldUnited Healthcare (Not Dual complete or Apple health)I don't have health insurance / Self-pay or Private-PayOther
We are not contracted with Medicaid or Medicare (State insurance/Molina/Apple Health/United Dual Complete/Kaiser Medicare) plans and can't accept patients under these plans at this time.

The cost for self-pay is $150 for a follow-up visit (30-minute visit) or $300 for a new patient-visit (60-minute visit). Out-of-network plans are eligible for reimbursement and we can provide a superbill/detailed receipt. We understand that there are specific subsidiary plans under the insurance carriers listed below that are not included here. Call us at (253) 448-3271 or email us at hello@allgoodpsychiatry.com to see if we accept your insurance.
What's your insurance member ID?*
Type "NA" if you don't have insurance
What's your insurance group number?*
Type "NA" if you don't have insurance
Please provide the primary subscriber's full name, your relationship to the subscriber, date of birth, and address if you are not the primary subscriber.*
Type "NA" if you are the primary subscriber
Please upload your insurance card

A copy of the front and back
Cancelof
How do you prefer your appointment?*

TelehealthIn-Person
Which location do you prefer to visit for in-person appointments?*

Tacoma (2115 S 56th St, Ste 304, Tacoma, WA 98409)Lacey (655 Golf Club Pl SE, Ste A, Lacey, WA 98503)
Please tell us your preferred time and days of the week for your appointment?*
Please upload a copy of your ID

Cancelof
How did you hear about us?

Google Search / Google AdPsychology TodaySocial Media (FB, Instagram)ZocDocHeadwayAlmaTherapy DenReferral form other providers or therapistsReferral by an All Good patientWord of MouthOther
Anything else you want us to know?
Submitting this form DOES NOT guarantee an appointment. Your request has to be reviewed and approved within 1-3 days. Once approved, we will reach out to you to schedule your new patient intake appointment. (If we can't get a hold of you after numerous attempts, we are going to assume that you are no longer interested to proceed and will have to cancel the request)
Should be Empty: