[2026] AFP Pre-Intake Form

Request Your Appointment

Step 1 of 2: We will email your secure clinical portal link within 1 business day (Mon-Fri, 8 AM - 5 PM EST)
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
Zip Code
We apologize, but Alis Family Psychiatry is currently only accepting patients who reside in Virginia or Oregon. We cannot proceed with your intake at this time.

Primary Insurance
Patient's Relationship to the Primary Policyholder / Sponsor
Please type the name of your insurance company
Which insurance were you hoping to use?
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 New Patient Evaluation 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.
Primary Policyholder / Sponsor First & Last Name
Primary Policyholder / Sponsor Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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

Cancelof
Back of Insurance Card

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

Cancelof
Front of Secondary Insurance Card

Cancelof
utm_source
utm_medium
utm_campaign
Referred by / How did you hear about us?
Please specify the name of the Provider, Clinic, or Practice.
Would you like us to coordinate care and send a visit summary back to this referring provider?
Which platform (e.g., Instagram, Facebook, TikTok)?
Final Acknowledgements
LEGACY - Referred by / How did you hear about us?
State of Residence
Should be Empty:

Request Your Appointment

Final Acknowledgements