Where are you located?
*
Please Select
New Jersey
New York
Pennsylvania
Select your state
What can we help you with?
*
Initial Evaluation
Medication Management
Injured Worker
Not sure / Something else
Medication Management
*
I’m already taking prescribed medication
I need a new prescription
Not using medication
Current Medication(s)
Alprazolam (Xanax)
Amitriptyline (Elavil)
Amphetamine/Dextroamphetamine (Adderall, Mydayis)
Aripiprazole (Abilify)
Asenapine (Saphris)
Atomoxetine (Strattera)
Brexpiprazole (Rexulti)
Bupropion (Wellbutrin, Zyban)
Buspirone (Buspar)
Carbamazepine (Tegretol, Carbatrol)
Cariprazine (Vraylar)
Chlordiazepoxide (Librium)
Chlorpromazine (Thorazine)
Citalopram (Celexa)
Clomipramine (Anafranil)
Clonazepam (Klonopin)
Clonidine (Kapvay)
Clozapine (Clozaril)
Desipramine (Norpramin)
Desvenlafaxine (Pristiq)
Dexmethylphenidate (Focalin)
Dextroamphetamine (Dexedrine, Zenzedi, ProCentra)
Diazepam (Valium)
Doxepin (Silenor, Sinequan)
Duloxetine (Cymbalta)
Escitalopram (Lexapro)
Eszopiclone (Lunesta)
Fluoxetine (Prozac)
Fluphenazine (Prolixin)
Fluvoxamine (Luvox)
Gabapentin (Neurontin – off-label use for anxiety)
Guanfacine (Intuniv)
Haloperidol (Haldol)
Hydroxyzine (Vistaril, Atarax)
Imipramine (Tofranil)
Isocarboxazid (Marplan)
Lamotrigine (Lamictal)
Levomilnacipran (Fetzima)
Lisdexamfetamine (Vyvanse)
Lithium (Eskalith, Lithobid)
Lorazepam (Ativan)
Loxapine (Loxitane)
Lurasidone (Latuda)
Methylphenidate (Ritalin, Concerta, Daytrana, Metadate)
Midazolam (Versed)
Mirtazapine (Remeron)
Nortriptyline (Pamelor)
Olanzapine (Zyprexa)
Oxcarbazepine (Trileptal)
Paliperidone (Invega)
Paroxetine (Paxil)
Perphenazine (Trilafon)
Phenelzine (Nardil)
Propranolol (Inderal – off-label for performance anxiety)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Selegiline (Emsam – transdermal patch)
Sertraline (Zoloft)
Temazepam (Restoril)
Thioridazine (Mellaril)
Topiramate (Topamax)
Tranylcypromine (Parnate)
Trazodone (Desyrel, Oleptro)
Triazolam (Halcion)
Trifluoperazine (Stelazine)
Valproic acid / Divalproex sodium (Depakote)
Venlafaxine (Effexor)
Vilazodone (Viibryd)
Vortioxetine (Trintellix)
Zaleplon (Sonata)
Ziprasidone (Geodon)
Zolpidem (Ambien)
What do you take this medication for?
*
ADHD
Addiction
Anger Management
Anxiety
Bipolar Disorder
Career Counseling
Child or Adolescent
Coping Skills
Couples Counseling
Depression
Dissociative Disorders
Domestic Violence
Eating Disorders
Family Conflict
Family Therapy
Foster Care/Adoption
Grief
Insomnia/Sleep Issues
Learning Disabilities
LGBTQ
Life Transitions
Men's Issues
Military/Veterans
Mood Disorders
Obsessive-Compulsive (OCD)
Older Adults
Parenting
Peer Relationships
Personality Disorders
Phobias
Post Partum
Racism
School Issues
Self Esteem
Self-Harming
Serious Mental Illness
Sex Therapy
Sexual Abuse
Spirituality
Substance Misuse
Suicidal Ideation
Trauma and PTSD
Women's Issues
What brings you here today?
*
ADHD
Anger Management
Anxiety
Bipolar Disorder
Coping Skills
Couples Counseling
Depression
Domestic Violence
Eating Disorder
Family Conflict
Family Therapy
Grief
Insomnia/Sleep Issues
Learning Disability
Life Transitions
Men's Issue
Mood Disorder
Obsessive-Compulsive (OCD)
Older Adults
Parenting
Peer Relationships
Personality Disorder
Phobia
Post Partum
PTSD
School Issues
Self Esteem
Self-Harming
Sex Therapy
Sexual Abuse
Sexuality Issues
Spirituality
Suicidal Ideation
Trauma
Women's Issues
Do you have health insurance?
*
Amerigroup
Anthem
Cigna
Empire BlueCross BlueShield
Highmark Health
Horizon BlueCross BlueShield
Independence Health System
Medicaid
Medicare
NJ Family Care
Optum
Tricare
United Health
Wellcare
Self-pay
I don't have insurance
I'm not sure
Who is this appointment for?
*
Myself
My child
Someone else (dependent)
I am a:
*
Individual
Provider
Employer
Case Manager
Attorney
Other
Have you worked with PAX before?
*
Yes, I have an existing relationship or portal access.
No, this is my first time
What best describes your situation?
Work-related injury / Workers’ compensation case
Disability claim
Motor vehicle accident (no-fault)
Name
*
First Name
Last Name
Email
*
john@pax.health
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Provide Case Details
Address
Street Address
Street Address Line 2
City
State
Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Gender as listed on insurance
Female
Male
Decline to Specify
Other
How did you hear about us?
Please Select
Primary Care Doctor
Psychiatrist
Employer
Insurance Company
Friend or Family Member
Online Search (Google, Bing, etc.)
Social Media
Previously a PAX patient
When are you generally available for appointments?
*
Early morning (8–10 AM)
Late morning (10 AM–12 PM)
Afternoon (12–4 PM)
Evening (after 4 PM)
Flexible / Anytime
Gender preference
Please Select
Male
Female
N/A
Language preference
Please Select
English
Español
Français
Deutsch
Português
Italiano
Nederlands
Русский
中文 (简体)
中文 (繁體)
日本語
한국어
العربية
Türkçe
हिन्दी
বাংলা
اردو
Polski
Українська
Ελληνικά
עברית
To access the portal and continue working on your case
Click here
To access the portal and continue working on your case
Click here
To access the portal and continue working on your case
Click here
Submit
Should be Empty: