Dr. Elaine Orabona Foster
Prescribing Psychologist
Phone Call Request Form
I am a prescribing and clinical psychologist. I provide short-term (usually 12 weeks) psychotherapy. I can provide medications when necessary. Let's chat a bit before making our first appointment. Getting to know you before scheduling an in person assessment, will help determine if my services are right for you. All answers are confidential.
Name
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First
Last
Which Insurance do you use? I accept the following:
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Blue Cross Blue Shield
Presbyterian
Centene/Western Sky
Medicare
Self Pay
Please enter the full name of your insurance:
Your Contact Number
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Please enter a valid phone number.
Email Address
example@example.com
What services are you interested in?
Talk therapy
Talk therapy and psychiatric medications
Psychological Testing
Other
Why are you reaching for help at this time? Be as detailed as you can.
What are your goals for contacting me?
Please check any of the following you have experienced in the past six months
Increased appetite
Decreased appetite
Trouble concentrating
Difficulty sleeping
Excessive sleep
Low motivation
Isolation from others
Fatigue/low energy
Low self-esteem
Depressed mood
Tearful or crying spells
Anxiety
Hopelessness
Panic
Other
Please check any of these medical conditions that apply to you.
Headache
High blood pressure
Gastritis or esophagitis
Hormone-related problems
Head injury
Angina or chest pain
Irritable bowel
Chronic pain
Loss of consciousness
Heart attack
Bone or joint problems
Seizures
Kidney-related issues
Chronic fatigue
Dizziness
Faintness
Heart valve problems
Urinary tract problems
Fibromyalgia
Numbness & tingling
Shortness of breath
Diabetes
Hepatitis
Asthma
Arthritis
Thyroid issues
HIV/AIDS
Cancer
What else would you like me to know?
Do you currently have a primary care provider?
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No
Yes
These are the times I'm available to contact you:
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