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:*

By PhoneBy EmailOther

Referred by:

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

Mark Monfasani PMHNP-BCSusan Ulery PMHNP-BCEric-Paul "EP" Olsson PMHNP-BCNo Preference/Soonest Available

Please provide the reason(s) for seeking services:*

Do you currently have Health Insurance coverage?*

YesNo (for Self-Pay)

Please select your Health Insurance provider:*

Please indicate the sex associated with this plan:*

MaleFemale

In-person/Telehealth Availability:*

In-person onlyHybrid (in-person and telehealth)

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:*

MorningsAfternoonsEveningsOther

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

YesNo

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.