[2026] AFP Pre-Intake Form

Request Your Appointment

Step 1 of 2: We will email your secure clinical portal link within 1 business hour (Mon-Fri, 8 AM - 5 PM EST)
Patient Full Name

Patient's Legal First NamePatient Last Name
Patient Email
example@example.com
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Date of Birth

MonthDayYear
Date
Legal Sex (For Insurance)
State of Residence
Zip Code

Primary Insurance
Patient's Relationship to the Primary Policyholder / Sponsor
We apologize, but Alis Family Psychiatry is currently only accepting patients who reside in Virginia. We cannot proceed with your appointment request at this time.
Primary Policyholder / Sponsor First & Last Name
Primary Policyholder / Sponsor Date of Birth

MonthDayYear
Date
Member ID / Subscriber #
Please enter the exact ID found on your insurance card.
Sponsor ID (Required for Tricare Verification)
Reason for visit:
Please Note: Our practice does not provide psychotherapy (talk therapy or counseling). We specialize in psychiatric medication management and neurocognitive testing only.
Front of Insurance Card

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Back of Insurance Card

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Do you have a secondary health insurance policy?
Back of Secondary Insurance Card

Cancelof
Front of Secondary Insurance Card

Cancelof
Requested Insurance Network (Optional)
Which insurance were you hoping to use?
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utm_medium
utm_campaign
Referred by / How did you hear about us?
Should be Empty:

Request Your Appointment