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: 1199 Aetna Beacon Health Value Options Blue Cross Blue Shield Cigna Medicare NYShip Empire Oxford United Behavioral Health United 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 disability Please check service(s) you are interested in: Medication Management Psychiatry TMS Neuromodulation Sleep Medicine Esketamine Treatment Mind-Body Wellness Preferred Time of Consultation:Urgent1-3 weeks4+ weeks
