Appointment Request Form

We want to make sure we meet your needs. The details you share today will help us match you with a provider who has experience helping people with similar challenges, so the more you share the more effective we will be. Please be as detailed as possible and rest assured that the information you share with us is confidential. Please allow 2 business days for a response.

Online scheduling is not for emergency situations. If you are in an immediate crisis, please phone 911 or go to your closest emergency room; or dial 988 to reach the Suicide and Crisis Lifeline. I am not in a crisis and understand the review of this online intake document may take up to 2- Business Days

I Acknowledge

Patient's First Name:

Patient's Middle Name:

Patient's Last Name:

Patient's Phone number:

Patient's Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Patient's Email Address:

Patient's Date of birth?

Patient's Sex?

MaleFemalePrefer Not to Answer

What is the name of your insurance company, or will you be a self-pay patient?

Please describe in detail the reason you are seeking our services today.

Are you interested in talking to a therapist to explore your feelings and develop some coping skills?

YesNo

Are you looking for someone who can prescribe medications that allow you to live well again?

YesNo

In your own words, describe any current problems as you see them. For example, are you experiencing; a lack of concentration, irritability, loneliness, sadness, or difficulty sleeping?

Is there a current psychiatrist/therapist? If so, who?

Currently being prescribed any psychiatric medication?

YesNo

If yes, which medication?

Are you requesting a specific practitioner, or a male or female? If so, who is requested?

The next three questions address use of alcohol and other drugs. If there is no current usage, your response to the following questions should be N/A or Not Applicable.

↳ What is the substance and how often is the usage?

↳ Are you seeking treatment for this issue at LCOH or elsewhere?

↳ Is there regular alcohol, marijuana or medical marijuana use?

Do you struggle with a behavioral addiction, such as gambling, shopping, pornography, or co-dependency?

YesNo

↳ If so, what is the behavior?

Thank you for your request.