New Appointment

Name: *

Read the following carefully - we will review this to determine if we offer services relevant to your needs so we can make sure if you have an appointment, your time is well-spent.

Insurance and Conditions Treated

Neighborhood participates with Aetna, BCBS, United Healthcare, Oxford and Cigna. If you do not have coverage for these plans, you will be required to pay out-of-pocket as your insurance may not cover our services. Please note: We specialize in treating common conditions including depression (e.g. Unipolar Depression), anxiety disorders (Generalized Anxiety Disorder, Social Anxiety Disorder, etc.), ADHD, and related lower-severity conditions.

In order to provide proper, comprehensive care, we generally do not prescribe medications during the initial consultation period. In order to prescribe controlled substances, including common medications for anxiety (e.g. Xanax, Ativan, etc.) and ADHD (Adderall, Ritalin, Vyvanse, etc.).

We are REQUIRED BY LAW to check New York's I-STOP prescription registry and note any concerning prescriptions with other prescribers.

We recommend patients with more intensive or specific needs seek treatment in an appropriate care setting.

For example, the care of substance use disorders like Alcohol Use Disorder requires addiction psychiatry treatment, and people with serious and persistent conditions including Bipolar Disorder, Schizophrenia and Psychotic Disorders are recommended to seek treatment with a specialist in those conditions, or in a specialized care setting.

Neighborhood Psychiatry uses a team model.

Following initial evaluation, if you begin treatment with us, you may work with another clinician within our practice or you may remain under the care of the evaluating clinician. The majority of our patients as a matter of practice clinical guidelines will be under the care of a Psychiatric Medical Doctor (MD or DO) and Psychiatric and Mental Health Nurse Practitioner (NP), with more regular visits with your NP and Psychiatrist check-ins periodically and as clinically indicated. Again, please refer to the financial responsibility form and your healthcare plan for details as to how your out-of-pocket expense may vary as a result of your coverage.

If you are experiencing a medical or psychiatric emergency, or believe you may be a risk to yourself or others, please call 911 or go directly to the nearest emergency department. We do not offer emergency services.

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email *

Phone: *

How did you hear about us? *

Name of person who referred you (if applicable)

Insurance and Payment information: We are In-Network with the listed carriers in most cases. If you have have coverage out of network with another plan, please enter the name in 'Out-of-Network'. We also offer Self-Pay options at reasonable rates for people with whom we are not in-network. Please note that we are not In-Network with Medicare or Medicaid Managed Care Plans.: *

Aetna Cigna BCBS United Healthcare/Oxford Self-Pay

Please provide your Insurance Member ID # and your Date of Birth so that we can help determine the insurance benefits you are entitled to.

Member ID # *

Enter Member ID for In-Network, ID# and Type of Insurance with Out-of-Network coverage, or Self-Pay if you do not have insurance coverage.

Please complete the following screening questions

Providing this information allows us to determine whether we are likely to have appropriate services or if we may best help you by assisting with a referral outside of Neighborhood Psychiatry for specialized or more intensive services than we can offer.

We cannot guarantee referral, however, and are not a placement service. We understand it is difficult to find care, and we regret we cannot treat all seeking care or find appropriate referrals. This information will be used only to determine insurance coverage and appropriateness of Neighborhood Psychiatry for services. Please note that we do not provide weekly psychotherapy.

Date of Birth *

What are the main reasons you are seeking evaluation and treatment? *

I'm looking for: *

Evaluation and Referral Medication Management (Psychopharmacology) Transcranial Magnetic Stimulation TeleTherapy Neurofeedback/EEG Biofeedback TelePsychiatry

Have you been in treatment with Neighborhood Psychiatry in the past? *

Yes No

Are you looking for an immediate prescription, whether for a standard psychiatric medication or a controlled medication? *

(Yes/No/Other) : If yes, we will require appropriate medical records and/or discussion with past or current providers, and possible additional evaluation, before providing prescription refills. We will not take a patient into care until we have had a chance to complete a full evaluation to determine safety and appropriateness of requested treatments for our treatment setting.

Current, Past or Suspected Psychiatric Diagnoses *

Are you currently receiving behavioral health care (e.g. psychiatry, therapy, etc.)? If so, please briefly describe. *

Do you have any past or current problems with substance use, addictions or other compulsive behaviors? If yes, please describe the issues you have had, negative consequences, and treatment (e.g. detox, rehab, etc.). Include alcohol and other drug use, eating disorders, self-injury (e.g. cutting oneself, skin picking, etc.), gambling, internet, sex addictions/compulsions, or other related behaviors causing distress, dysfunction, complaints from others, or problems in work, school or relationships. *

Do you have any significant psychiatric history at any time in the past including past treatment, hospitalization, psychiatric emergency room visits, overdoses, blackouts, aggression, self-injury, etc.? If yes, please specify: *

Have you experienced any of the following? (Please check all that apply, and please report accurately so we can determine if we have the facilities required to provide proper care before you come in for an initial evaluation. We can not treat all patients who come in for evaluation.) *

Suicidal thoughts in the last 2 years? Suicidal or self-harming behaviors in the last 2 years? Hallucinations, strong false beliefs or paranoid thoughts in the last 2 years? Excessive or problematic use of alcohol, any other substance, gambling, internet use, disordered eating, pornography or any other compulsive or addictive behaviors in the last 2 years? Psychiatric hospitalization, including Emergency Department visits, in the last 2 years? Use medical marijuana either prescribed or obtained informally? Take any over-the-counter supplements, nutriceuticals or mail-order prescriptions? Use alcohol or illicit substances in a way which may impact your well-being?

If "yes" to any of the above items, please specify: *

Have you ever tried to take the life of yourself or anyone else, tried to injure yourself or anyone else, or had thoughts or urges to injure yourself or others? *

Yes No

Please note any CURRENT medications you take, and for what. Include psychiatric and other medications. *

Please note any significant Medical History, including current medical illness, past surgeries, medication allergies, accidents, injuries, signifiant prior illnesses, or childhood developmental difficulties. *

Are you pregnant, trying to become pregnant, or seeking treatment for post-partum problems? *

Please note we recommend consultation with a Reproductive specialist if the answer to any of the above is "Yes".

Please note any PAST medications you have taken, and for what. Include psychiatric and other medications. *

How often do you miss or cancel appointments on short notice? Please pick one option: *

Never Rarely Sometimes Often Regularly

Today's Date *

Date

You've completed this Pre-Consultation Screening. By submitting this request, you acknowledge and agree to the following:

We require 2 business days notice to reschedule or cancel your appointment. Business days are M-F, excluding weekends and holidays.

Our cancellation/missed appointment fee for initial appointments is $150.00, and $100.00 for follow-up visits. This fee applies to both missed appointments and appointments changed or cancelled with less than 2 business days notice. Your are responsible for these fees, and insurance does not cover them. We collect credit card information in order to hold your appointment time and to charge fees for regular treatment, missed appointments, and late cancellations.

Please check your email and make sure your voicemail is accepting messages.

If you don't hear from us, it means we are busy responding to a high volume of inquiries. Please contact us again. We appreciate your understanding.

Medications are not usually prescribed on a first visit. Additional evaluation, including access to past medical records, laboratory or psychological testing, and so on, may be required as part of evaluation in order to make sure we offer appropriate and safe psychiatric treatment. Please bring any records you have to your first appointment, or have them sent in advance to expedite your care.

If Neighborhood Psychiatry is unable to provide treatment, I will receive evaluation and recommendations for treatment and referral as appropriate.

Please make sure you know your insurance plan benefits so you are not surprised by fees from deductibles, co-pays, and other costs including uncovered fees. Inquiries of coverage and benefits through Neighborhood Psychiatry is not a guarantee of payment as information provided by insurance companies on initial benefits review may be inaccurate. Patients are responsible for all fees not covered by insurance plans.

Completing evaluation does not mean I have started treatment at Neighborhood. If I do start treatment, this will be discussed as part of the treatment plan, and I will receive a treatment agreement outlining what to expect.

I consent to the use of electronic communication and give permission for Neighborhood Psychiatry to use the information I provided to check my benefits and determine if we can provide appropriate services. I understand the above policies, and agree to them. I have accurately reported my information so Neighborhood Psychiatry can make the best determination regarding scheduling an initial consultation.

Please note that due to an unusually high volume of referrals, it may take 1-2 weeks to receive a response to appointment requests, and up to several weeks for an available initial consultation time slot. We apologize for this inconvenience and are working to keep up with the higher rate of requests.

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