sopsychiatry.com - New Patient Request Form

New Patient Request Form
We are unable to see patients under the age of 18 at this time. Please consult your primary care provider or insurance for a child/adolescent psychiatry referral.
Full Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age*
Seeking Help For:
Type of Payment
Insurance Company Name*
We are in-network with Moda, Pacific Source & Regence BlueCross BlueShield. Unfortunately we are unable to accept Medicare or Medicaid (OHP) at this time.
Email
example@example.com
Please be sure to include an accurate email. If your request is accepted, you will be invited to create a patient portal account where you will complete your intake paperwork.
Is it ok to send reminders or information to this email address?

YesNo
Phone Number
Is it ok to send reminders or information to this phone number?

YesNo
Referred from:

Psychology TodayInsuranceFriendPrimary Care ProviderTherapistInternetFamily MemberOther
Current Diagnosis:

DepressionAnxietyBipolar DisorderADHDEating DisorderSubstance Use DisorderSchizophrenia/SchizoaffectivePersonality DisorderNoneOther
Past Mental Health Hospitalization?

YesNo
When?
Where?
Current Medication List
If you are currently not on any medications, please check the box.
Any other information you would like to include?
Should be Empty: