New Patient Adult Appointment Request

Thank you so much for your interest in our practice. Currently, none of our providers specialize in this particular area. By continuing with your submission, you understand that we may refer you to another provider who can best meet your needs.

Psychiatry- MedicationTherapy- Talking and Problem-Solving TechniquesTreatment Resistant Depression treatment- TMS, Spravato, KetaminePsychoeducational TestingMedical Marijuana

Thank you so much for your interest in our practice. We don't currently offer that service at our practice. By continuing with your submission, you understand that we may refer you to another provider who can best meet your needs.

MondayTuesdayWednesdayThursdayFriday
Morning (9am-12pm)Early Afternoon (12pm-3pm)Late Afternoon (3pm-5pm)
Please provide a list of all current and previous medications taken for mental health. Include the medication name and dosage. *

Primary Insurance Company*
Member ID Number*
Please upload your primary insurance card (front)

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Please upload your primary insurance card (back)

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Secondary Insurance Company
Member ID Number
Please upload your secondary insurance card (front)

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Please upload your secondary insurance card (back)

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Have you (or the patient if you are filling out on their behalf) experienced any of the following?
Feeling that someone can hear your thoughts or you could hear what another person was thinking?*
Hearing things other people couldn't hear, such as voices even when no one was around*
Consistently drinking at least 4 drinks of any kind of alcohol in a single day *
Using medication without a doctor's prescription or using drugs*
Significant problems of maintaining independence due to having a developmental disability*

Being currently non-verbal due to a developmental disability*
A manic episode diagnosed by a healthcare provider*
A psychotic episode diagnosed by a healthcare provider*
An eating disorder, either currently or in the past*
A mental health hospitalization*
If yes, please include the date and reason for the hospitalization
Attending a Partial Hospitalization Program (PHP) or Intensive Outpatient Program (IOP)*
Deliberately hurting yourself physically*
Making a suicide attempt*
Having your closest relationships troubled by a lot of arguments or repeated breakups*
Physical aggression toward others*
Having been arrested*
Having at least two problems with impulsivity*
Being extremely moody*
Feeling or acting in an angry or sarcastic manner*
Chronically feeling empty*
Feeling that you have no idea who you are or have no identity*
Making desperate attempts to avoid feeling or being abandoned*

COVID-19 & Infectious/Communicable Disease Liability Waiver

Please read and acknowledge the following:

COVID-19 Safety Measures
Our office is no longer implementing additional COVID-19-specific precautions (such as universal masking, enhanced distancing, or routine screening) beyond standard infection control protocols required by healthcare regulations.
Personal Responsibility
By entering our facility, you acknowledge that:
- You are voluntarily seeking care and services at our office.
- You understand that COVID-19 remains a communicable illness with potential health risks.
- You are responsible for your own personal precautions (e.g., masking, distancing, sanitizing) if you so choose.
Health Disclosure
You agree to inform our staff prior to your visit if you:
- Have tested positive for COVID-19 within the past 10 days.
- Have been exposed to someone known or suspected to have COVID-19 within the past 10 days.
- Are experiencing any symptoms consistent with COVID-19 (including but not limited to fever, cough, fatigue, or loss of taste or smell).
Assumption of Risk
Despite our efforts to maintain a clean and safe environment, you acknowledge that:
- There is an inherent risk of exposure to COVID-19 in any public or healthcare setting.
- By attending your appointment, you voluntarily assume all risks related to potential exposure.
Student / Trainee Participation Consent Blue Umbrella Psychiatry participates in the clinical training of medical students and other healthcare trainees under the supervision of Dr. Eric Robbins and our licensed providers. At times, a student or trainee may observe or participate in appointments as part of their education.Your participation is completely voluntary, and your care will not be affected if you choose to decline. You may also change your preference at any time.Please indicate your preference:*

Yes, I consent to having a student or trainee observe or participate in my appointments under provider supervision.No, I prefer not to have a student or trainee present during my appointments.

HIPAA Policy

Our office is committed to maintaining compliance with HIPAA regulations to ensure
the privacy and security of patient information. Once an appointment is scheduled, the patient will receive our full HIPAA policy to review, outlining our practices and
procedures for safeguarding their confidential health information.
Establishing Care with Our Practice

A psychiatric evaluation by Dr. Robbins or one of our clinicians does not ensure you
will become a patient of the practice. It may be his/her opinion that you need more
intensive services from what can be provided in the office. At that time, Dr. Robbins
will provide you with referrals of programs you can receive such services from. If after the completion of your evaluation with your clinician, he or she feels you can be treated in the office, certain recommendations will follow. You will be required to follow the recommendations provided by the clinician during the course of treatment. If for any reason, the clinician feels you are not complying with the recommendations, you may be discharged from the office for non compliance. Other reasons you may be discharged from the office include: repeatedly missing appointments, not being responsive to phone calls from office, failure to make payments in a timely manner or any misuse of medications being prescribed to you by your clinician. If you are discharged from the office and are being prescribed medications, your clinician will make sure to provide you with enough refills for up to 1-2 months to give you ample time to connect with a new provider.
Working with Our Practice

I understand that my initial appointment may be scheduled with either Dr. Eric Robbins, a licensed psychiatrist, or with a qualified psychiatric nurse practitioner, depending on provider availability and scheduling needs. While I may request a first appointment with Dr. Robbins, earlier appointments may be available with one of the practice’s experienced psychiatric nurse practitioners.

In addition to psychiatric medication management, Blue Umbrella Psychiatry provides therapy services through licensed therapists and supervised clinical interns. Depending on your treatment needs, care may involve collaboration between psychiatric providers, therapists, and/or clinical interns as part of a coordinated treatment approach.

All psychiatric nurse practitioners, therapists, and interns practicing within Blue Umbrella Psychiatry work under the clinical oversight and medical directorship of Dr. Eric Robbins. As part of providing comprehensive and coordinated care, members of the treatment team may consult with one another regarding your case to support clinical decision-making and continuity of care. This may include internal case consultation when patients receive multiple services within the practice, or when more than one member of a family is receiving services.

Any such consultation occurs solely for purposes of treatment, care coordination, and supervision within the practice and is conducted in accordance with applicable privacy laws and confidentiality standards.

By signing below, I acknowledge and consent to receive care from the qualified providers within Blue Umbrella Psychiatry as determined by clinical judgment, treatment needs, and provider availability.
I affirm that all information provided above is accurate and complete to the best of my knowledge. I understand that submission of this information does not guarantee an appointment with this practice. I acknowledge that the New Patient Coordinator may review my information and, based on clinical and logistical considerations, may recommend an alternative provider or practice better suited to my needs.
Signature*
Patient Name*
Date*
Patient Name, signature if printed
Should be Empty:

Appointment Request Form

Thank you so much for your interest in our practice. Currently, none of our providers specialize in this particular area. By continuing with your submission, you understand that we may refer you to another provider who can best meet your needs.

Thank you so much for your interest in our practice. We don't currently offer that service at our practice. By continuing with your submission, you understand that we may refer you to another provider who can best meet your needs.

COVID-19 & Infectious/Communicable Disease Liability Waiver

HIPAA Policy

Establishing Care with Our Practice

Working with Our Practice