Alis Family Psychiatry - Patient Intake

Request Your Appointment

Step 1 of 2: Once we verify your benefits (typically within 1 to 2 business days), we will text and email your secure intake forms link to unlock scheduling.
Patient Full Name

Legal First NameMiddle 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
2 digit month, 2 digit day, 4 digit yearDate
Legal Sex (For Insurance)
Address

Street Address

Street Address Line 2

CityState

Zip Code
System Mode
Expected Payment Method
Patient's Relationship to the Primary Policyholder / Sponsor
Member ID / Subscriber #
Please enter the exact ID found on your insurance card.
11-Digit DoD Benefits Number (DBN)
(Found on the back of your ID card)
Please type the name of your insurance company
Which insurance were you hoping to use?
Sponsor ID (Required for Tricare Verification)
Primary Policyholder / Sponsor First & Last Name
Primary Policyholder / Sponsor Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Self-Pay (Cash) Care Options

We pride ourselves on delivering elite, highly personalized psychiatric care without the restrictions of insurance networks.

Our self-pay rate for a Comprehensive 60-Minute Diagnostic Psychiatric Evaluation & Treatment Plan is $250, and follow-up medication management visits are $195.

For your convenience, we provide a detailed "Superbill" after each visit upon request. You can submit this directly to your insurance provider for potential out-of-network reimbursement.

Request Your Appointment

Final Acknowledgements