Eros Consultation Form

1
For privacy, consent, and accuracy, the individual seeking care must complete this questionnaire and schedule their consultation directly. This request for consult cannot be completed by a partner, family member, or any third party. This ensures I can best understand your needs and provide appropriate support.
2
Are you currently experiencing a medical or psychiatric emergency? (Including active suicidal thoughts or immediate danger to yourself or others)

If yes, please do not continue this form. Seek immediate help by going to the nearest emergency room or calling 911.

For mental health crisis, you can also contact the 988 Suicide and Crisis Lifeline, available 24/7 for free, confidential support by calling or texting 988.
3
Please note that I do not provide services for individuals who:

Have a legal guardian or are under a conservatorship for medical or psychiatric care.

Are currently engaged in, or anticipate becoming involved in, criminal or civil litigation.

Have been ordered by a judge, or referred by an attorney or law firm, to obtain an evaluation.

Are requesting care for work, security, or firearm clearance, fitness-for-duty, or return-to-work evaluations.

You will need to seek care from a forensic psychiatrist, forensic psychologist, or provider who specializes in medico-legal matters.
4
Please enter information below. * This field is required.
Please Select
Please Select
Family/Friend
Physician
Search engine (such as Google)
Therapy Website (such as Psychology Today)
Other
How did you hear about Eros Psychiatry?
Full Name (First, Last)
Date of Birth (XX/XX/XXXX)
Please enter your phone number
Please enter your email
City, State you currently live in
5
Eros Psychiatry & Sex Therapy is private pay only/not in network with any insurance companies. Superbills can be provided upon request. Are you ok with moving forward?* This field is required.
YESNO
6
Are you enrolled with any of these plans?* This field is required.Medicare, Medicaid (Medi-Cal, AHCCCS, Texas Medicaid), Tricare/TriWest, Kaiser Permanente?
YESNO
7
All appointments with Eros Psychiatry & Sex Therapy are held virtually through a secure, HIPAA-compliant platform. In-person appointments are not available. Are you ok with moving forward?* This field is required.
YESNO
8
What services are you seeking?* This field is required.
Psychiatric Care
Sex Therapy
Both
I'm not sure
9
As a fully virtual practice providing care across multiple states, I do not prescribe controlled substances such as stimulants (ex: Adderall, Vyvanse), benzodiazepines (ex: Xanax, Klonopin), or certain sleep and pain medications. These medications require in-person monitoring and are regulated differently across states. I am also not able to take over existing prescriptions for controlled substances or manage tapers as this requires in-person oversight. If at any point a controlled medication is indicated, I can write a letter to an outside provider recommending these prescriptions, though whether they agree to prescribe will be at their discretion. Additionally, psychiatric care does not include hormone management. This includes hormone replacement therapy (HRT) for gender-diverse care, testosterone replacement therapy (TRT) for hypogonadism/testosterone deficiency, and hormone management related to menopause or other gynecologic conditions. If these limitations are reasons not to pursue psychiatric care with me, I completely understand. You are welcome to see me for therapy. Are you ok with moving forward?* This field is required.
YESNO
10
Why are you seeking care?* This field is required.please check all that apply.
Anxiety/OCD
ADHD and/or neurodivergence
Bipolar disorder
Compulsive sexual behaviors
Depression
Disordered eating
Grief and loss
Issues commonly faced by the LGBTQ+ community
PTSD and/or trauma related issues
Relationship difficulties
Sex, love, and/or intimacy issues
Struggles with body image and/or embodiment
Substance use
Other
11
You checked LGBTQ+ issues, please describe them here:
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Ok
12
You checked relationship difficulties, please describe them here:
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Ok
13
You checked sex, love, and intimacy issues, please describe them here:
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Normal
Small
Ok
Ok
14
You checked disordered eating, please describe them here:
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Ok
Ok
15
You checked struggles with body image and/or embodiment, please describe them here:
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Ok
16
You checked Substance use, please describe that here:
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Ok
17
What is your history with mental health?* This field is required.Select all that apply.
In therapy now
In therapy in the past
Taking psychiatric medications
Have taken psychiatric medications in the past
Hospitalized for mental health reasons now or within the last year
Have been hospitalized for mental health reasons in the past
Attempted suicide or self-harmed in the past
Have attempted suicide or self-harmed in the past
Known neurologic or genetic disorder
None of these apply
18
Is there anything else you would like Dr. Champion to know?
19
Thank you for taking the time to complete the screening. Unfortunately, I am not able to work with you based on your responses. I encourage you to connect with a provider who better matches your needs, and wish you the best as you move forward with care.
20
Based on your responses, you are not currently eligible for services at Eros Psychiatry & Sex Therapy.

Due to federal and state legal restrictions, individuals enrolled in any of the following programs are not able to receive services, regardless of private pay preference:

Medicare

Medicaid, including:

Medi-Cal

AHCCCS

Texas Medicaid

Tricare / TriWest (military health plans)

Kaiser Permanente

These programs prohibit patients from paying out of pocket for services that may be covered by their plan, even if they are not using their insurance. If you are currently enrolled in one of the above programs, I am legally unable to provide care. This is not a policy based on preference or judgment, but one required for legal and regulatory compliance.
21
I understand that submitting this questionnaire and scheduling a consultation does not guarantee ongoing treatment, nor does it establish a patient-physician relationship. You will be redirected to the scheduling page, YOU MAY NEED TO DISABLE YOUR POP-UP BLOCKER.* This field is required.
Agree and continueDisagree
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