Intake Pre-Screen
Complete this pre-screen so we can match you with the most appropriate psychiatric service and clinician. Please note that many fields are not required! The ones with a little star * beside them are.
What are you looking for?
Which services are you seeking?
Adolescent psychiatry
Adult psychiatry
I'm not sure
KAP (Ketamine-Assisted Psychotherapy)
Medication management
Psychotherapy
Spravato evaluation or treatment
Other
What are you hoping to get help with?
ADHD
Anxiety
Autism
Bipolar disorder
Depression
Gender dysphoria
Grief
Mood swings
OCD
Schizophrenia
Sleep issues
Substance use
Trauma/PTSD
Other
Please briefly describe your main concerns or goals
How soon are you hoping to get started?
As soon as possible
Within 2 weeks
Within 1 month
Just exploring options
Preferred appointment type
Telehealth
In Person
Either
Other
Preferred times of day
Early morning (before 10)
Late morning (10–12)
Early afternoon (12–3)
Late afternoon (3–5)
Evening (after 5)
Preferred days of the week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Who would you like to work with?
Don't know? Select "help me choose" and our care coordinators will help you get scheduled with your best fit.
Preferred clinician
Please Select
Help me choose
Dr. German Ascani, MD
Harry Chiang, Ph.D. MSCP
Laura Richardson, Ph.D., MSCP
Lindsay Shaw, Ed.D. MSCP
Additional matching preferences
About you
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Okay to text
Best way to reach you to schedule
Phone
Text
Email
Are you filling out this form for yourself or someone else?
Myself
Someone else
Submitter's name
Relationship
Are you a parent/guardian or legal representative?
Parent/guardian
Legal representative
Neither
Payment Options
How will you pay for your visit?
*
Out of Pocket (Full Fee, Sliding Scale)
Insurance
Insurance provider
Member ID
Group number
Upload the front of your insurance card
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload the back of your insurance card
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Are you covered by any other insurances?
Yes
No
Safety and clinical history
Have you been diagnosed with any condition that could require urgent or emergency care?
Yes
No
Not sure
Are you currently taking psychiatric medications?
Yes
No
Do you have a current therapist?
Yes
No
Do you have a current or previous psychiatrist or prescriber?
Yes
No
This form is not monitored for emergencies. If you are in crisis, call or text 988 or go to your nearest ER.
*
Please share any other important information we should know before scheduling your visit.
Submit
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