Consultation Request – MP Psych Care
Complete this form to request a mental health consultation and help us understand your needs.
Disclaimer: This form is for general informational purposes only and is not monitored for emergencies. If you are experiencing a crisis or emergency, please call 911 or go to the nearest emergency room.
Patient Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
State
*
Please Select
Kansas (KS)
Missouri (MO)
Eligibility
Are you currently located in Kansas (KS) or Missouri (MO)?
*
Yes
No
Are you seeking telehealth services?
*
Yes
No
Reason for Consultation
What brings you in?
*
Please describe your symptoms or concerns.
*
Current Treatment
Are you currently taking any psychiatric medications?
*
Yes
No
Are you currently seeing a provider for mental health?
*
Yes
No
Services Interested In
Which services are you interested in?
*
Evaluation
Medication Management
Therapy
Not sure
Insurance / Payment
How do you plan to pay for services?
*
Insurance
Self-pay
Unsure
Availability
Preferred days and times for consultation
*
Safety Screen
Are you currently experiencing thoughts of harming yourself or others?
*
Yes
No
Warning: This form is not monitored for emergencies. If you are experiencing thoughts of harming yourself or others, please call 911 or go to the nearest emergency room immediately.
Acknowledgment
Please confirm all of the following:
*
I understand this is not an emergency form.
I understand submitting this form does not guarantee services.
I consent to being contacted regarding this request.
Signature
Full Name (Signature)
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit Consultation Request
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