EP CONTACT FORM

Request For Services

Please use this form to request correspondence regarding mental health services at Empowered Psychiatry by providing all the required information.

Legal Name of Individual Seeking Services:

First NameLast Name

Name Individual Goes By:

First NameLast Name

DOB:

MonthDayYear

Name of Legal Guardian:

First NameLast Name

Gender Identity:

please specify

Pronouns Used:

please specify

Contact Phone:

Area CodePhone Number

Contact Email:

example@example.com

Preferred Method of Communication:

Other

Referred by:

Preferred Location:

Preferred Clinician (we try to accommodate requests depending on availability):

Please provide the reason(s) for seeking services:

Do you currently have Health Insurance coverage?

Please select your Health Insurance provider:

Please indicate the sex associated with this plan:

In-person/Telehealth Availability:

Please note: Intake appointments and Individuals under the age of 18 are seen in-person only. Telehealth is available, but depending on your treatment plan, it may be required that you are seen in-person by your provider on a regular interval.

Appointment Availability:

Other

Have you been hospitalized in the last 90 days for psychiatric purposes?

Please describe the circumstances:

By submitting this form, you authorize Empowered Psychiatry and its staff to contact you in reference to your request using the contact details you have provided above. Form data will be encrypted and securely transmitted over the internet. Your information will remain confidential and used only for the purposes indicated above.