Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Any history of psychiatric or neurological illness ? (If yes, please place diagnosis or symptoms) *

NO

YES

Any history of substance or alcohol abuse ? (if yes, describe) *

NO

YES

Are you currently taking any prescription medication (if yes, report medication and dosage) *

NO

YES

Have you ever been hospitalized for psychiatric or neurological reasons ? (if so how many times and last admission) *

NO

YES

Is this consultation for disability evaluation, accommodations or legal purposes ? *

NO

YES

Will you be using insurance or fee for service (self pay) ? *

Unfortunately, we do not accept Healthcare Marketplace insurance plans

OUT OF NETWORK / SELF PAY (1x $400, follow-up $180)

BLUE CROSS BLUE SHIELD PPO (1x $100 deposit)

AETNA (PPO, EPO) (1x $100 deposit)

AETNA NORTHWESTERN STUDENT INSURANCE (1x $100 deposit)

CIGNA (1x $100 deposit)

Were you referred by anyone ? (if yes, please provide contact)

NO

YES

Currently all appointments are online:

https://doxy.me/peaklifemd