Request Appointment Full Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Phone*Email* Referral source:Online/WebsiteInsuranceList of Accepted Insurances:1199AetnaBeacon Health Value OptionsBlue Cross Blue ShieldCignaMedicareNYShip EmpireOxfordUnited Behavioral HealthUnited HealthcareInsurance Name*Member ID:*How much is your yearly deductible?:Did you meet your yearly deductible?: Choose oneYesNoReason for Consultation: *Current SymptomsDuration of SymptomsCurrent Medications, if anyPlease check if you have any of these diagnoses: schizophrenia bipolar disorder substance abuse recent hospitalization any ongoing psychiatric disabilityPlease check service(s) you are interested in: Medication Management Psychiatry TMS Neuromodulation Sleep Medicine Esketamine Treatment Mind-Body WellnessPreferred Time of Consultation:Urgent1-3 weeks4+ weeks
