Prospective New Patients

If you would like to be a new patient, please fill out and submit the form below. All information being transmitted is confidential. Virginia Integrative Psychiatry is NOT an emergency mental health facility.  If you are in crisis, please call 911 or go to the nearest emergency room.

Person Submitting this form *

Email

Relationship to potential client *

Home Phone

Cell Phone

Patient Name (If different from submittor)

Patient Date of Birth

Patient Street Address

City

State Virginia Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code

Reason for submission? Referred by? *

Migraines? Headaches?

Yes

No

Are you currently taking:

Marijuana

CBD

Kratom

Is the PNP requesting suboxone treatment?

Yes

No

If suboxone, are there any legal issues?

Current medications currently being taken (if applicable)

Which antidepressants have been prescribed in the past?

If using your health insurance, please select your carrier

Anthem/Blue Cross Blue Shield

Aetna/Innovation Health

Cigna

Please digitally sign below to signify that:

For addiction treatment, we do not accept checks at the first appointment.

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Office staff cannot guarantee that a specific medication will be prescribed. Requests for specific medications must be made directly to clinical staff.

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If you will be out of medications prior to your appointment with a prescribing staff, you must contact your prior psychiatrist/primary care physician for a refill.

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Intake appointments may be cancelled if prior medical/counseling records are not provided before or at the time of the intake appointment.

Signature

Clear

If you are human, leave this field blank.

Currently we are only accepting new patients for TMS (transcranial magnetic stimulation). If you have been on 4 or more antidepressant medications, you may be a candidate for this new state of the art treatment. Please call our office for more information.

Currently, we are not seeing children under age 17.