New Patient Appointment Request I am currently not taking any more pediatric patients at this time (under 18); this may change in the near future and I will update this form when that occurs.
This is step 1 of 2 before you can book an appointment. Once this request is submitted you will receive further intake paperwork that has to be reviewed before you are approved to schedule. Please review which insurance plans I accept on my website prior to filling out this form.
Are you a current patient or have you been seen by Danielle Fitch in the previous 3 years?
Please Select
yes
no
Patient Name
Legal First Name
*
Legal Last Name
*
Preferred Name
Patient Details
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is the patient under age 18?
*
Yes
No
Guardian Details
*
First Name
Last Name
Relationship to Patient
*
Please Select
Parent
Legal Guardian
Grandparent
Sibling
Other
Parent/Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Contact
Email Address for Next-Step Instructions After Request is Submitted
*
example@example.com
Phone Number That You Consent to for Contact
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Text
Are you requesting urgent or emergency support today?
Yes
No
I understand this form is not for emergencies.
*
I understand
Care Request
Type of Service Sought (TO BE CLEAR, I AM NOT A THERAPIST)
*
Medication Management and currently on medication
Medication Management currently NOT on medication
Evaluation for alternative options
Diagnosis Evaluation
Not sure
Brief Description of Help Needed
*
Insurance
How do you plan to pay for services?
*
Insurance
Self-pay (Cash Pay)
Insurance carrier
examples: Wellmark/BCBS, Anthem, UnitedHealthcare, UMR, Aetna, Midlands, Cigna
Insurance plan type
Please Select
PPO
HMO
Medicaid
Medicare
Marketplace
Employer plan
Please be aware if you have a HDHP (High Deductible Health Plan) and the potential cost if you have not reached your deductible. I do not take Medicare or Medicaid.
Member ID
Save
Submit New Patient Request
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