Request an appointment 112822

Request an appointment
Welcome to Foresight!

We're so glad you're here. We're excited to have the opportunity to support you on your path to well-being.

In order to get you scheduled as soon as possible, we'll use the information you provide to schedule your first appointment directly.
First Name*
Preferred Name
Last Name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date Of Birth*

MonthDayYear
Date
Sex (as listed on insurance policy)*

MaleFemale
What is your current gender identity? (Check one)

MaleFemaleTransgender Male/Trans Man/Female-to-Male (FTM)Transgender Female/Trans Woman/Male-to-Female (MTF)Genderqueer, neither exclusively male nor femaleChoose not to discloseOther, please specify
What are your pronouns?
Street Address 1*
Street Address 2
e.g., Apt #, Suite #
City*
State of Residence*
Services are available only in the states listed above.
Zip Code*
What type of care are you seeking? (select all that apply)*

Individual TherapyFamily TherapyCouples TherapyPsychiatry/Medication ManagementNutritionEAPADHD Testing
What type of care are you seeking? (select all that apply)*

Individual TherapyFamily TherapyCouples TherapyNutritionEAP
What type of care are you seeking? (select all that apply) CA*

Individual TherapyFamily TherapyCouples TherapyPsychiatry/Medication ManagementNutritionADHD Testing
What type of care are you seeking? (select all that apply) GA*

Individual TherapyFamily TherapyCouples TherapyPsychiatry/Medication ManagementNutritionEAPADHD Testing
What type of care are you seeking? (select all that apply)*

Individual TherapyFamily TherapyCouples TherapyPsychiatry/Medication ManagementNutritionEAPADHD Testing
What type of care are you seeking? (select all that apply)*

Individual TherapyFamily TherapyCouples TherapyPsychiatry/Medication ManagementNutritionEAPADHD Testing
Today's Date

MonthDayYear
Date
Age - Years
Name Of Parent Or Guardian*

First NameLast Name
Email Address Of Parent Or Guardian*
example@example.com
Phone Number Of Parent Or Guardian*
Please enter a valid phone number.
If available in your area, are you interested in being seen in-person at one of our offices?*

YesNoSometimesNo preference
Please include the name, date of birth, phone number, email address and physical address (if different) for all participants
Insurance Provider*
To confirm your share of the cost of care, we recommend you reach out to your insurance provider.
University
Subscriber ID*
Are you the primary subscriber of this insurance policy?*

YesNo
Primary Subscribers Name*

First NameLast Name
Primary Subscribers Date Of Birth*

MonthDayYear
Date
Authorization #*
Authorization Start Date*

MonthDayYear
Date
Authorization End Date*

MonthDayYear
Date

When are you available for an appointment?*

	Monday	Tuesday	Wednesday	Thursday	Friday
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm

If a weekly slot isn't available, are you okay with being scheduled every other week to start? Your therapist will work with you to determine the right care plan.*

YesNo
Preferred Provider
If provider is unavailable a similar provider may be offered
Do you require a provider of a specific gender for your care?*

No PreferenceMaleFemaleNon-binary
Consent to SMS Text messaging*

YesNo
Terms for scheduling Therapy

If you are seeking Therapy services, due to high demand and limited availability, we will book your sessions based on information provided on this form. Once you have been booked, we will send you a confirmation email and text message*, if you’ve opted to receive texts from us. We book multiple sessions in the time slot we find for you only to hold your place with that provider. After your first meeting with your clinician, you and your clinician will collaborate to decide if ongoing treatment is right for you, if there are any considerations that would be better supported from another provider or treatment, and if you’d like to keep future sessions. We provide outpatient mental healthcare services at Foresight and your needs may require a higher level of care than what we offer.

^*Mobile data rates may apply
Please note the following disclaimers regarding Psychiatry appointments
- Disability requests are at the discretion of the provider and typically only granted after an established relationship has been developed.
- At Foresight, we require testing before the prescribing of any stimulant medications for ADHD. If you have previous in depth neuropsych testing or IVA testing, we can waive this requirement.
  - Please upload your previous testing prior to your appointment to allow your provider to review for sufficiency.
  - If testing is required, the cost is $200 and it is conducted virtually.
- Your initial appointment is an evaluation in which assessment will be conducted and treatment recommendations may or may not be made until a follow up appointment depending on the amount of information needed.
- Medication is not guaranteed to be continued at its same dose or frequency as it is up to the discretion of the provider to make treatment recommendations based on their assessment.
I have read and understand the terms of scheduling my appointment(s).*

YesNo
How did you hear about us?

Insurance referralOnlinePsychology TodayUniversity referralProvider referralCurrent Foresight memberCare SolaceCharlie HealthZAMA HealthOther Parents Like MeInternet advertisementInternet searchOther
If you are having thoughts of harming yourself or someone else to the extent of having means, intent and/or access, and those thoughts are impacting your activities of daily living, please contact 911 or the National Suicide Prevention Lifeline at 988.

We provide outpatient mental healthcare services at Foresight and your needs may require a higher level of care than what we offer.
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