Alpha Psychiatry - Appointment Request - New Patients

How did you hear about us?
Hospital, Wellness centers
Center name
Primary Care
Provider name
Therapist
Therapist name
Insurance/Payer
Company name
Internet search
Patient Information

This is the description of your section break.
Patient Name Patient Name * First Last
Phone Phone * - ### - ### ####
Date of Birth Date of Birth * / MM / DD YYYY
Email *
When do you want the appointment? *

(For urgent /crisis appointments, please call our office)
Preferred Day(s) of the Week

Preferred Day(s) of the Week Monday Tuesday Wednesday Thursday Friday
Preferred Time

Preferred Time Morning (8:30a - 10:30a) Midday (10:30a - 1p) Afternoon (2p - 3:30p) Evening (3:30p - 5p)

(Fridays, we close at 3:00 PM)
Primary Reason for Appointment *

Primary Reason for Appointment Anxiety ADHD Depression Stress Opioid Addiction Treatment Family/Marital Counseling Psychological testing for ADHD Other Other
Home Address Home Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Insurance Carrier *

NOTE:

* We do take BCBS, but DO NOT take Blue Home Network (Blue Home will pay their out of network deductibles).

* We do not take Medicaid.
Other insurance company (specify name) *

Insurance company name since you chose "Other" option for Insurance carrier above.
Insurance Member ID *
Preferred Provider Type *

Preferred Provider Type Psychiatrist/Medication Provider Therapist (talk therapy, counseling only) Psychologist for psychological testing

Please select both Therapy and Psychiatrist, if you need both types of appointments.
Preferred Location
Preferred Provider for Cary
Preferred Provider for Durham
Additional Information

To ensure your information is verified before the visit.
Chief Complaint Narrative *

Note: Required to assign a suitable provider.
Brief History: If you have been treated for mental healthcare in the past. *

This is important information for us to be able to assign a provider better equipped for your care.
Current medications ONLY for the mental health diagnosis. (Enter "Not Applicable", if you have not seen a mental health provider in the past) *

This is important information for us to be able to assign a provider better equipped for your care.
Additional Information (optional)

(Such as appointment time/date and any other requirements needed to be given to the doctors/healthcare service providers)
Have you been treated for substance abuse in last 12 months? *

Have you been treated for substance abuse in last 12 months? Yes No
If Yes, please provide more information
I certify that I am not seeking controlled substance prescriptions. For any medication prescriptions, I understand that I will be evaluated by the Psychiatrists at Alpha Psychiatric Associates and my treatment plan will only be based on the diagnosis by the Psychiatrists. *

I certify that I am not seeking controlled substance prescriptions. For any medication prescriptions, I understand that I will be evaluated by the Psychiatrists at Alpha Psychiatric Associates and my treatment plan will only be based on the diagnosis by the Psychiatrists. I acknowledge
I understand that Alpha Psychiatry will not provide me disability paperwork upon initial visit. I acknowledge that Alpha Psychiatric Associates may not help me with long term disability paperwork. For short term disability paperwork, I may be evaluated further during 3-4 follow-up visits, or may be required to participate in intensive care treatments. *

I understand that Alpha Psychiatry will not provide me disability paperwork upon initial visit. I acknowledge that Alpha Psychiatric Associates may not help me with long term disability paperwork. For short term disability paperwork, I may be evaluated further during 3-4 follow-up visits, or may be required to participate in intensive care treatments. I acknowledge

Alpha Psychiatry - Appointment Request - New Patients

How did you hear about us?

Patient Information

Additional Information