Alpine - Intake Form

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Important Information Before Starting with Alpine Psychiatry

Alpine Psychiatry is an in-network mental health practice specializing in psychiatric medication management and psychotherapy. We currently have therapy availability for children 12+, adolscents and adults. We accept most major commercial insurance plans and Medicare. This office does not accept Medicaid at this time.

Prior Inpatient Care: If you've had inpatient hospitalizations (within the past 12 months), Alpine Psychiatry may not be able to provide your needed level of care. We will, however, address this on a case by case basis through our intake team.

Disability Paperwork: Alpine Psychiatry does not fill out disability paperwork until you have been an established patient for at least 6 months.

Communication: Our practice relies heavily on a HIPAA compliant text platform called "Spruce" for most patient contacts. This allows our providers and staff to respond efficiently to patient inquiries and requests. Patients 14 years and older must have their own account.

Credit Card: An active credit card is required to be placed on file for copays and co-insurance charges prior to scheduling an appointment.

Cancellation Policy: There is a 48-hour (business days) cancellation policy. Failure to cancel within this window will result in a $175 fee for evaluations and a $95 fee for follow up appointments. This charge will be to the credit card on file.
Agreement: By submitting this form, you confirm that you understand and agree to Alpine Psychiatry's policies and procedures.
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Lead Status* This field is required.
New Lead
Contacted, No Answer/Reply (attempt 1)
Contacted, No Answer/Reply (attempt 2)
Contacted x 3 - no response, Lost Lead
Contacted, Scheduling In Progress
Patient Scheduled! Woohoo!
Contacted, No Answer/Reply (attempt 3)
Other/Pending follow up
Lost Lead - N/A
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What services are you interested in?* This field is required.
Therapy
Medication Management
Both
4
Are you inquiring for yourself or someone else?* This field is required.
Myself
Someone Else
5
What is your name?* This field is required.
First Name
Last Name
6
What is the patient's name?* This field is required.
First Name
Last Name
7
What's the preferred contact email?* This field is required.
example@example.com
8
What's the preferred contact phone number?* This field is required.
9
What's the reason for the Visit?* This field is required.A brief statement of what is going on with the patient. Please list any DIAGNOSES. Main reason why you are seeking services: Symptoms, thoughts, stability & behaviors
Huge
Large
Normal
Small
Ok
Ok
10
How did you hear about us?* This field is required.
Online search
Another health care provider
Friend/family member
Quartet
Insurance
School/College
Other
11
Are you willing to share the name of the provider who referred you?Please provide their name and contact information
Provider
12
Have you wished you were dead or wished you could go to sleep and not wake up?* This field is required.
YESNO
13
Have you actually had any thoughts about killing yourself? * This field is required.
YESNO
14
Have you been thinking about how you might do this?* This field is required.
YESNO
15
Have you had these thoughts and had some intention of acting on them?* This field is required.
YESNO
16
Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan?* This field is required.
YESNO
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Have you done anything, started to do anything, or prepared to do anything to end your life? * This field is required.Ex: taken pills, cut yourself, tried to hang yourself, or collected pills, given away valuables, wrote a will or suicide note, took pills out but didn't swallow any, went to the roof but didn't jump, etc.
YESNO
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Was this within the past 3 months?* This field is required.
YESNO
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Based on your responses, it appears that our outpatient model does not fit your needs. We are recommending a higher level of care that allows for more immediate access and ability to effectively interven in case of an emergency. Below you'll find a list of reliable resources that we frequently recommend to clients seeking care with similar needs. Please let us know if there is anything additional we can do to help.

Intensive Outpatient Programs (aka "IOP", which are 90 mins, 3-5x per week) and Partial Hospitalization Programs (aka "Day Programs" held daily, 9am-3pm):

The Horsham Clinic
Offers inpatient and partial hospitalization programs in multiple regions and for various ages.
215-643-7800

Senare
This is a newer program that has programs for all ages in many parts of Philadelphia.
610-344-9600

High Focus Treatment Centers (IOP/PHP)
Intensive outpatient and partial hospitalization programs for mental health or drug/alcohol issues.
610-644-6464

Mirmont Treatment Center
Run by Main Line Health, they offer many levels of care including Intensive outpatient, partial hospitalization, and inpatient programs for mental health or drug/alcohol issues.
888-CARE898

Womens Emotional Wellness Center
Run by women, for women and offering both IOP and Partial programs.

National Suicide Prevention Lifeline: Call 1-800-273-TALK (8255) for 24/7 free and confidential support.
Crisis Text Line: Text HOME to 741741 to connect with a trained crisis counselor for free, 24/7 support via text message.

Local Crisis Centers:
Montgomery County’s Mobile Crisis: 855-634-HOPE (4673)
Chester Country's Mobile Crisis: 610-280-3270
Delaware County's Mobile Crisis: 1-855-889-7827
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