Southeast Virginia Psychiatry
Appointment Request Form
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
*
/
Month
/
Day
Year
Gender
How did you find us?
Friend recommendation
Doctor referral
Internet search
Provider directory search
Other
What is the reason you are seeking services with us?
Have you seen a mental health professional before?
Yes
No
If yes, what was the reason for treatment? What was your diagnosis, if any?
Specify all psychotropic medications you are currently taking, including the dosages.
Do you have, or have you ever had, a problem with self-harm (e.g., cutting, scratching, hairpulling, etc.)?
Yes
No
Do you have, or have you ever had, suicidal thoughts?
Yes
No
If yes, when? If yes, how would you end your life?
Have you ever been hospitalized for a psychiatric issue?
Yes
No
If yes, where were you hospitalized? When did this happen? What was the reason you were hospitalized?
What is your current occupation? What do you do? How long have you been doing it?
Do you currently drink alcohol?
Yes
No
If yes, describe the type, amount, and how often (daily, weekly, monthly, etc.):
Do you currently use recreational drugs?
Yes
No
If yes, describe the type, amount, and how often (daily, weekly, monthly, etc.):
Any non-mental health related medical conditions? (e.g. hypertension, diabetes, asthma, etc..)
What else would you like me to know?
Who is your primary insurance carrier?
Please Select
CASH PAY
MEDICAID
AETNA BETTER HEALTH (MEDICAID)
HEALTHKEEPERS PLUS (MEDICAID)
UHC COMMUNITY PLAN (MEDICAID)
OPTIMA/SENTARA (MEDICAID)
MOLINA (MEDICAID)
HUMANA MEDICARE HMO PLAN
ANTHEM/ HK / BCBS / BLUE CROSS PLANS
BLUE CROSS FEDERAL (prefix “R”)
CIGNA
SENTARA COMMERCIAL (NON MEDICAID)
AETNA (COMMERCIAL PLANS)
TRICARE
MEDICARE
UNITED HEALTHCARE (COMMERCIAL PLANS)
Please upload your insurance card:
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If you have a secondary insurance, please upload your secondary insurance card:
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Please upload any additional insurance, doctor referral, psychiatric testing, or other relevant documents:
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