Redemption Psychiatry - Prospective Patient Submit


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Redemption Psychiatry - Prospective PatientsRedemption 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. NOTICE: Due to unforeseen circumstances beyond our control we are not able to schedule new patients in our Gilbert and Chandler offices at this time. Our Phoenix and Glendale offices are able to accept new patients if that is convenient for you. What Insurance Carrier(s) do you have? Primary: Secondary (if any): Insurance Information: (please provide the following numbers): Insurance ID: Group ID: Please complete the insurance section before clicking NEXT. Patient's Name: First: Middle: Last: Patient Birth Date: Age: SSN: What is the sex of the patient? Male Female The Patient's Address: Street Address: City: State: Zip code: The following information is for the insurance subscriber if different from the patient: (if same check this box ) Subscriber's Name: Subscriber's Birth Date: Subscriber's SSN: Subscriber's Address, City, State & Zip: Address: City: State: Zip: Who referred you to our office? Please complete the Demographics section before clicking NEXT. Are you being discharged from a hospital and need an urgent appointment? Yes: No: We will need a copy of the record from that hospitalization or evaluation for your appointment. Please answer the discharge question before clicking NEXT. Please answer the following questions to see if you would benefit from our Advanced Depression Treatment program. 1. Were you being treated for depression or suicidal thoughts/behaviors? Yes: No: 2. Have you been treated with 4 or more antidepressant medications? Yes: No: 3. Have you tried counseling/therapy? Yes: No: 3a. If no, did you participate in counseling while inpatient? Yes: No: 4. Have you been diagnosed with a psychotic disorder (ever) or substance abuse (within the last 6 months)? Yes: No: 5. Do you have a medical provider who prescribes your psychiatric medication? Yes: No: 5a. If yes, are you looking for a new provider or are you in need of an urgent appointment but plan on following up with your regular provider? Yes: No: Please answer all questions before clicking NEXT. Check the reason(s) and/or interest(s) for the desired appointment? Depression Post-Partum Depression Hospital Discharge ADHD Anxiety/Stress Bipolar Disorder Behavioral Disorder Sleep Problems PTSD OCD Other Issues Advanced Depression Treatment program candidates will get a priority appointment. Please select at least one reason before clicking NEXT. Please answer the following questions to see if you would benefit from our Advanced Depression Treatment program. 1. Does your depression cause significant impairment or distress in at least one area of life (work, school, marriage, social, family, etc.)? Yes: No: 2. Have you been dissatisfied with the results of antidepressant medication treatment? Yes: No: 3. Have you tried counseling/therapy? Yes: No: 3a. If no, are you interested in non-medication options for depression other than therapy? Yes: No: 4. Have you been diagnosed with a psychotic disorder (ever) or substance abuse (within the last 6 months)? Yes: No: 4a. If no, are you interested in non-medication options for depression other than therapy? Yes: No: Please answer all the questions before clicking NEXT. Please Provide your Contact Information. (must enter only valid phone and email address) Phone Number: Email Address: Choose Your Preferred Location(s): Arrowhead Chandler Gilbert Metro Phoenix Any Office What kind of provider do I need? Doctor/Nurse Practitioner: I need a diagnosis and possibly medication, but NOT THERAPY. Therapist: I only need therapy/counseling. Advanced Treatment: I am interested in superior treatment options that can help patients who are not satisfied with conventional treatments (medication and therapy) or want to avoid medications. 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.		New Patient Appointments Faculty Biographies TMS Therapy Is TMS for you? What is TMS? Play Attention! for ADHD Emergencies Routine Prescription Refill Form Patient Forms Patient Handouts Advocating For Our Patients Fees & Cancellation Policy Our Colleagues Patient Portal Groups: Adoption Support Group Social Skills Group 8-12 Anger & Mood Mgmt- Boys 13-17 Parents of Seriously Ill Children Redemption Psychiatry Affiliates: Aurora Behavioral Health Care Phoenix Weight Loss - Medical Weight Loss Center
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