Reschedule Psych evaluation exception request form

Reschedule Psych-Eval exception request form

It is the policy of JADE Wellness Center that psychiatric evaluations will not be rescheduled if a client does not attend the appointment and fails to cancel at least 24 hours in advance.If you missed your psychiatric evaluation without prior cancellation, you must provide a written explanation outlining the circumstances that prevented you from attending or canceling in advance. This information will be reviewed by the treatment team to determine the appropriate next steps regarding your care and potential rescheduling.Please complete the fields below to submit your explanation.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Which site was your assessment scheduled at?

MonroevilleSouthsideWexfordTelehealthUnsure
What was the date of your missed psychiatric evaluation?

MonthDayYear
Date
Please specify why you did not attend this assessment or cancel within 24 hours of your appointment.
The infromation above will be sent to one of our clinical directors to review within 72 hours. A team member will let you know the determination of your request upon its review.

Thank you,
Should be Empty:

Reschedule Psych-Eval exception request form