Psychiatric Consultation Request & Clinical Prescreen

Psychiatric Consultation Request & Clinical Prescreen

To ensure safe and appropriate care, all prospective patients must complete this request prior to scheduling. After submission, the clinician will review your information and, if appropriate, you will receive an email with available appointment times.This is not a crisis service. If you are in danger or having a mental health emergency, call 911 or dial 988.
Full Legal Name:*
Date of Birth:*

MonthDayYear
Date
Email Address:*
example@example.com
Mobile Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
County (Kansas):*
We can only see patients who are physically located in Kansas at the time of the visit.
If you are not located in Kansas, please seek care locally or contact 988 for support.

Medication Policy: Benzodiazepines

This practice does not prescribe or continue benzodiazepines under any circumstance. This includes medications such as alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin), diazepam (Valium), temazepam (Restoril), and similar medications.If you are currently prescribed a benzodiazepine, you must taper with your existing prescriber before establishing care with this clinic.This policy is firm and applies to all patients.
YesNo
Which benzodiazepine medication(s)?
Current dose and frequency (example: 0.5 mg twice daily)?*
Current prescriber name and clinic?*
This policy applies to all patients, including those requesting care for anxiety, sleep, or panic symptoms. Alternative treatment options may be discussed when clinically appropriate.

Payment & Final Acknowledgment

After submission, your consultation request will be reviewed. If appropriate for outpatient telehealth care, you will receive an email with available appointment times.Scheduling is not automatic and is subject to clinical review.
InsuranceSelf-Pay
Insurance Carrier:*
Insurance Member ID:*
Upload front and back of insurance card (optional):

Cancelof
Yes
Should be Empty:

Reason for Consultation