Pre-Scheduling Questionnaire

Pre-Scheduling Questionnaire
Patient's Legal Name

First NameLast Name
Patient's DOB

MonthDayYear
Date
Your relationship to the patient:
Preferred email address
example@example.com
Preferred phone number
Please enter a valid phone number.Format: (000) 000-0000.
If the patient is a minor, who has legal custody of the patient?

Other
Patient's grade, if applicable
What services are you seeking in our office? (Check all that apply.)
Do you have a preferred provider(s)? See our website for provider bios
***Please note***

WFP is currently paneled with Anthem and Sentara commercial insurance. If you have Anthem or Sentara, we can bill them directly. If you have another carrier, please speak with our billing specialist about which services we are able to offer superbills for. We also have several licensed self-pay providers with more immediate availability.
What insurance do you have?
Do you have concerns regarding any of the following pertaining to the patient? (Check all that apply.)

Other
What are the primary concerns you'd like to address at this time?
Do you have any safety concerns with regard to the patient? This can include, but is not limited to, suicidal ideation, self-harming behaviors, homicidal ideation, hallucinations, etc.
Would you be able to attend sessions during the mornings or early afternoons? (Some providers may have limited late afternoon / evening availability at this time.)
Is there currently an open legal matter initiating your seeking services?
Is there anything else you'd like us to know that will help us match you with the appropriate services and provider?
How did you hear about us?
PLEASE NOTE: If it seems you have not received a response within 48 business hours, please check your spam folder.
Please be sure to click the submit button below!
Important Practice Information

Please note that our practice does not offer after-hours services. Patients experiencing life-threatening emergencies outside of their provider's normal business hours must dial 911 or report to their nearest emergency room. Patients with urgent treatment needs should not expect a response outside of normal business hours.
Network Participation

While not all of our providers participate with insurance, those that do participate solely with Anthem commercial plans. In the event that your provider is not in-network with your insurance plan, our practice can provide you with a superbill so that you can file out-of-network claims on your own behalf if your plan has out-of-network benefits. Please note that WFP providers do not participate with Medicaid or Medicare at this time.
Should be Empty:

Pre-Scheduling Questionnaire

Please be sure to click the submit button below!

Important Practice Information

Network Participation