New Client Interest Form

New Client Interest Form

Complete this form to share your contact info and the services you’re seeking for scheduling with Bliss Progressive Psychiatry.
Not for emergencies. If you are in crisis, call or text 988.
Client Contact Information
Legal Name

First NameLast Name
Preferred Name
Home state
Mandy is licensed in Kentucky, which means you need to be physically located in Kentucky at the time of your visit, whether you're seen in our Louisville office or by video. Many of our clients travel in from Indiana and elsewhere. If you live outside Kentucky, please still submit your interest form; we consider licensing in other states on an ongoing basis.
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Text Message Consent

I agree that Bliss Progressive Psychiatry may contact me by text at the mobile number I provided regarding my inquiry and scheduling. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help. Text is not a secure channel, so we keep messages brief and limited to logistics; anything clinical happens by phone or through our secure portal. Texting is not required to become a patient. You can reach us at 502-888-1494 or info@blisspsych.com instead.
Email
example@example.com
Referral Source
How did you learn of us?
Which provider referred you?
Who referred you?
Which directory?
How did you find us?
What services are you seeking?
Acknowledgments
Out-of-network acknowledgment

I understand Bliss Progressive Psychiatry is out-of-network with all insurance companies. ***Selecting this indicates you understand fees are due at the time of service. You may use HSA or FSA funds to pay for your care. If offered by your insurance plan, we will provide you with a superbill to submit to your plan for partial reimbursement or to apply to out-of-network deductibles. It is your responsibility to investigate this option with your insurance provider.***
Medicaid attestation

I am not enrolled in any Medicaid plan (primary, secondary, or supplemental). ***Checking this box serves as attestation that you are not enrolled in any Medicaid plan. Per Kentucky law (907 KAR 3:005), Medicaid recipients found to be paying cash for services that would be covered with Medicaid-enrolled providers (ex: medication management or psychotherapy) can be subject to having their case audited. Such an audit may identify seeking care outside of Medicaid as fraud, resulting in their Medicaid or other assistance (such as SNAP) being suspended or terminated. The Medicaid enrollee would then be required to pay the government back for the cost of any Medicaid and SNAP benefits they have received.***
Should be Empty:

New Client Interest Form

Client Contact Information

Referral Source

Acknowledgments