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  • Request for Appointment

  • IMPORTANT

    Please fill out this request for an appointment with as much information as possible.The submission process may take upwards of 30 minutes however this process will give us the appropriate information about whether or not we are able to meet your treatment needs. Incomplete forms will not be considered for appointments.

    You will need to submit a photo of your insurance card on this form. Please take a photo of the front and back of your insurance card and have it saved on your computer or phone before starting this form. If we do not have a copy of this card we cannot verify benefits and no appointment will be offered.

    WE ARE NOT IN NETWORK WITH AHCCCS, MEDICARE, TRICARE, WORKERS COMP, OR EAP programs.

    WE ARE NOT IN NETWORK WITH MOST MEDICARE ADVANTAGE PLANS

    The only Healthcare Marketplace plan we are in network with is AmBetter.

    We are Out of Network for all plans purchased on the Healthcare Marketplace other than AmBetter.

    Please note that submission of this form does not guarantee an appointment nor does it constitute a patient-physician relationship.

    We are unable to see anyone under the age of 17.

    Appointments are scheduled on a case by case basis based on Appointment and Physician availability.

    There is currently a wait list for new patients. 

  • Any and all life threatening emergencies need to be immediately evaluated at an emergency facility.

    Do not continue this form and please immediately go to the nearest emergency room or dial 911.


    Tucson Community Crisis Line:
    If you are in  immediate crisis, whether it be for you or your loved one, call the Community Wide Crisis line at (520) 622-6000 or 1 (866) 495-6735.

    The National Suicide Prevention Lifeline is a 24-hour, toll-free, confidential suicide prevention hotline available to anyone in suicidal crisis or emotional distress. 1-800-273-TALK (8255).

    Tucson Healthcare Facilities:

    Banner University Medical Center – Emergency Room
    1625 N Campbell Ave, Tucson, AZ 85724
    (520) 694-0111

    Banner University Medical Center (South Campus) – Emergency Room
    2800 E Ajo Way, Tucson, AZ 85713
    (520) 874-2000

    Oro Valley Hospital Behavioral Health
    1551 E Tangerine Rd, Oro Valley, AZ 85755
    (520) 901-6250

    Palo Verde Behavioral Health
    2695 N Craycroft Rd, Tucson, AZ 85712
    (520) 322-2888

    Sonora Behavioral Health
    6050 N Corona Rd, Tucson, AZ 85704
    (520) 469-8700 or 1 (800) 349-0083

    St. Joseph’s Hospital – Emergency Room
    350 N Wilmot Rd, Tucson, AZ 85711
    (520) 873-3884

    St. Mary’s Hospital
    1601 W St Mary’s Rd, Tucson, AZ 85745
    (520) 872-4910

    Veterans Affairs Medical Center – Veterans Only
    3601 S 6th Ave, Tucson, AZ 85713
    (520) 792-1450

  • Please understand that Arizona Psychiatry is a medical practice whose physicians specialize in the diagnosis and treatment of behavioral health disorders.

    Medicolegal matters are often outside the scope of clinical medicine as they require expertise and communications to third parties, or may not involve both the diagnosis and treatment of a particular patient.

    We will likely need to discuss your specific requests in more detail to determine how we can assist you, but in doing so we ask that you not disclose any confidential or legally privileged information.

    Do not finish this form and please call our office for more information.

  • Please understand that Arizona Psychiatry is a medical practice whose physicians specialize in the diagnosis and treatment of behavioral health disorders. Our psychiatrists do not provide evaluations for work clearance, security clearance, generally suitability for work, suitability to own or posses a firearm, or approving return to work due to mental health issues.

    You will need to speak specifically with a forensically trained mental health expert for this type of evaluation.

     

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  • PLEASE NOTE THAT WE ARE NOT IN NETWORK WITH AHCCCS, MEDICARE, TRICARE, WORKERS COMP, OR EAP.

    IF YOU DO NOT SEE YOUR INSURANCE LISTED PLEASE DO NOT FILL OUT THIS FORM AND CALL OUR OFFICE.
  • Self-Insurance election (e.g.  "self-pay", "self-insured", "out-of-pocket", "cash-pay") requires  notification of applicable laws and policies, as well as your explicit  consent. While Arizona Psychiatry is an in-network provider with many  health insurance companies, we do not currently have relationships with  Medicare/Medicaid (AHCCCS) and some other select private insurers. In  these instances, someone may elect to be self-insured (or pay  "out-of-pocket") when either they do not have health insurance coverage,  when the healthcare provider or practice is "out-of-network", or when  patients explicitly do not want their insurance billed - instead  electing to pay out of pocket at the time of service. Generally, someone  who has health insurance coverage is obligated to submit healthcare  claims to the insurer for reimbursement. If you otherwise have insurance  or other types of health coverage, services received as "self-insured"  will not likely be reimbursed by your insurance carrier or applied to  your deductible, and may complicate your relationship with your health  insurance company. You may want to  discuss this and any repercussions with your insurance carrier before  pursuing this option. By signing below, you are simply acknowledging  that you have read this notification. We will speak with you in more  detail about it later and clarify any questions you may have.

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  • PHQ9

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  • Severity Measure for Panic Disorder

  • Panic attacks are sudden outbursts of anxiety that develop suddenly and increase in intensity within about 10 minutes.

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  • Severity Measure for Social Anxiety Disorder

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  • GAD-7

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  • PCL-C

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  • MDQ

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  • YBOCS

  • Obsessions are unwanted ideas, images or impulses that intrude on thinking against your wishes and efforts to resist them. They usually involve themes of harm, risk and danger. Common obsessions are excessive fears of contamination; recurring doubts about danger, extreme concern with order, symmetry, or exactness; fear of losing important things.

    Compulsions are urges that people have to do something to lessen feelings of anxiety or other discomfort. Often they do repetitive, purposeful, intentional behaviors called rituals. The behavior itself may seem appropriate but it becomes a ritual when done to excess. Washing, checking, repeating, straightening, hoarding and many other behaviors can be rituals. Some rituals are mental. For example, thinking or saying things over and over under your breath.

    Please answer each question by selecting the appropriate answer.

  • BPD

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  • NCI

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  • Prodromal Questionnaire - 16

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  • Disordered Eating Measure

  • Drug Abuse Screening Tool

  • Alcohol Use Disorders Identification Test

  • ASRS

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  • PLEASE PRESS SUBMIT TO COMPLETE THE REQUEST

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