New Patient Intake Form

Availability:  New patient appointments are currently available within 1 to 2 weeks. 

***Please note that all new patient appointments are conducted using telemedicine. We use a HIPAA compliant platform that requires patients to have a webcam on their phone or computer with a secure wifi connection. We will provide you with more details after completion of the intake form and after an appointment time has been confirmed. 

Rates/Appointment Details: 

Initial Visit/Psychiatric Evaluation $280 

The initial visit includes complete assessment of the patient’s chief complaint, history of present illness (recent stressors or symptoms), review of psychiatric symptoms and history, review of social and medical history, mental status examination, and  formulating a differential diagnoses and establishing a treatment plan with patient which usually includes reviewing medication treatment options and/or initiating medications if appropriate. The evaluation is scheduled for one hour or longer if needed. Commonly diagnosed conditions include Major Depression, Generlized Anxiety Disorder, Attention Deficit Hyperactivity Disorder (ADHD), and Sleep Disorders. 

Medication Management Session $140

Medication management sessions are scheduled for 30 minutes. The frequency of visits range from 1 to 3 months depending on the treatment plan and the patient’s needs. The focus of follow-up visits include medication management and supportive/insight-oriented counseling if needed.

Insurance Information:

Tim is currently NOT in-network with insurance plans. If you are eligible to receive reimbursement for your visits, we can kindly give you a form after each visit that you can submit to your insurance company for reimbursement. 

New Patient Intake: Please complete the fields below in full. When you are finished, please click “Submit” at the bottom (The more detailed the completion of the form, the better we are able to serve you!)

 ***Please note that any information submitted below is secure and confidential. Submitting a new patient request does not guarantee an appointment, nor does it establish a patient-provider relationship. Once the new patient intake is completed below, we will review your submission. If our provider determines he is able to evaluate and treat you with the information provided, we will contact you with additional information as soon as possible. Thank you for your time and patience!