New Patient Questionnaire Form

Please be advised that Medicaid will no longer cover medications written by our physicians. Only doctors that accept Medicaid may write prescriptions for Medicaid patients.

Payment is expected in full at the time of service. New Patient Psychiatry appointments are $550 and the Medication follow up appointments are $195. Psychology appointments vary and will be communicated in a follow up email.

"Late Cancellations" and "No Show" appointments (NOT cancelled at least 24 hours in advance) CANNOT be billed to the insurance company. The responsible party will be billed in full and will be responsible for these charges. If a "Late Cancellations" or "No Show" have occurred, a credit card will be required to keep on file for future appointments.

As we specialize in children and adolescents, our practice is open to a limited number of adults that present with minimal ADHD symptoms. More complicated situations are better referred to an adult psychiatrist .

Doctor:*

William Lee M.D. PsychiatristKristeen Spratley M.D. PsychiatristJohn C. Burnside M.D. Psychiatrist

Referred By:

Today's date:*

MonthDayYear

Is this case involved in a court case?*

YesNo

Who is this appointment for? Please provide potential patient information as it appears on legal documents.

Patient's legal name:*

First NameLast Name

Marital Status of the patient:*

SingleMarriedDivorcedWidow(ed)

Patient's sex:*

MaleFemale

Patient's age:*

Patient's birthdate:*

MonthDayYear

Name of school and Grade Level or Occupation of patient*

Parent Name / Guardian Name :

First NameLast Name

Marital Status of the parent / guardian:

SingleMarriedDivorcedWidow(ed)

Patient/guardian's address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Patient/guardian's phone #1:*

Area CodePhone Number

Patient/guardian's phone #2:

Area CodePhone Number

Patient/guardian's e-mail:*

Occupation of patient / Guardian*

Why are you requesting this appointment/ current concerns?*

Have there been other evaluations done or treatment and if so what and where?*

Please provide additional information regarding the patient's symptoms or needs.*

Have there been any previous MEDICATIONS tried*

New Patient Request Questionnaire