Care Transition Preferences

1

As a current patient of Dr. Surja, you have options for continuing your psychiatric care after January 31, 2026.

Please complete this brief form to let us know your preference so our team can review your request and determine appropriate next steps. You will receive a confirmation email after submission, and our team will follow up with you directly.

2

Name* This field is required.

First Name

Last Name

3

Date of Birth* This field is required.

Date

4

Email* This field is required.

example@example.com

5

Were you being treated for SUD (Substance Use Disorder)? * This field is required.SUD includes: Alcohol, THC, and other substances.

YESNO

6

If you were seeing Dr. Surja for substance use treatment, we recommend continued care with OSU Medicine’s Addiction Recovery Clinic, which offers comprehensive services and support for this level of care:

https://osumedicine.com/location/osu-addiction-recovery-clinic/

Phone: 918-561-1890

You may contact them directly for self-scheduling.

7

What would you like to do after January 31, 2026?* This field is required.

Continue care at Tulsa Family Psychiatry & Wellness with a different provider

Follow Dr. Surja to his self-pay practice

Request transfer of my medical records

I’m not sure yet / I’d like someone to contact me to discuss options

8

Preferred Contact Method* This field is required.

Phone

Portal Message

9

Phone Number* This field is required.

Please enter a valid phone number.

10

Any scheduling constraints we should know about? This field is optional.

Plese include any information you feel may be helpful about your scheduling preferences.

11

Self-pay Acknowledgement* This field is required.

I understand Dr. Surja will be practicing independently on a self-pay basis and will no longer be affiliated with Tulsa Family Psychiatry & Wellness.

12

We will reach out to you to gather more information for where you would like your records sent.

13

Referrer