Redemption Psychiatry Family Psychiatry
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Redemption Psychiatry - Prospective Patients
  Prospective Patient Form
If you are interested in a new patient appointment, please fill out this form as completely as possible. If you can't provide the requested information type "unknown" or "declined" but be aware that this may delay your ability to make an appointment.
     Patient's Name:  
     Patient Birth Date:       Age:
          What is the sex of the patient?        Male                 Female
      The Patient's Address: 
      Street Address:   
              City:   State: Zip code:
      Who referred you to our office?     
      Sorry, but we do not currently accept Medicare.
      Sorry, but we do not currently accept the insurance you selected, however we do offer the option of private pay.
      What is your Insurance Carrier?   
      Insurance Information: (please provide the following numbers):  
            Insurance ID:        Group ID:
  Have you recently been hospitalized or evaluated in an ER for a psychiatric reason?     Yes:       No:                 
  Are you seeking an appointment following discharge from an inpatient mental health facility?     Yes:       No:                 
      We will need a copy of the record from that hospitalization or evaluation for your appointment.
      Check the reason(s) and/or interest(s) for the desired appointment?
 ADHD Testing (QBtest)
 Anger Management
 Animal Assisted
 Attention Problems
 Autism Spectrum Disorder
 Behavior Coaching
 Behavioral Disorders
 Developmental Disorders
 Disability Claim Evaluation
 Eating Disorders
 Equine Therapy
 Hospital Discharge
 Impulse Control
 In Home Therapy
 Legal Issues/Cases
 Mood Disorders
 Naturopathic Treatment
 Panic Problems
 Personality Disorders
 Relationship Counseling
 Sleep Disorders
 Substance Abuse
 Tic Disorders
 TMS Treatment
 Trauma Issues
 Weight Loss
 Other Issues
      We must currently refer out any patients who need detox from alcohol, sedatives, or opiates.
      Note: Our providers do not see patients for legal evaluations.
      Be aware, that it may take several months to determine the level of impairment.
      Also, any documentation requires a fee of $20 per page, paid in advance.
      Unfortunately, we cannot guarantee success of a disability claim.
      We can evaluate patients for eating disorders but would provide a referral for any inpatient care.
      Have you ever been seen by another psychiatric provider?   Yes:      No: 
      Please give your doctor's name & briefly say why you want to change providers?   
  Please Provide your Contact Information.

            Phone Number:     Email Address:  
     Choose Your Preferred Location(s):
 Any Office
          Are you seeking a therapist or someone who can prescribe medication?
        Therapist                 Prescriber                 Both                 Unsure
          Select if you prefer a male or female provider?
        Male                 Female                 Either
       If you have a preferred provider select here:      

       If the provider you want is not in the list above, they practice at a location other than what you have selected.
Who should I see? If you need a medical diagnostic evaluation to determine treatment needs or if you may be in need of medication, schedule with one of our doctors. If you need a clinical/psychological evaluation and want to start therapy, schedule with one of our therapists. If you are going to need therapy and medications, request to schedule with both.”
New Patient Appointments

American Academy of Child and Adolescent Psychiatry
American Board of Psychiatry and Neurology
American Psychiatric Association
    Copyright © 2017 by Redemption Psychiatry, LLC