Alpha Psychiatry - Appointment Request - New Patients

During this COVID-19 pandemic, we offer Telemedicine appointments.

We request you to download Zoom apps appropriate for your device.
https://zoom.us/download
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)
PLEASE NOTE:

* Our providers do evaluate their patients and prescribe only what they believe is best for their patients.

* You may be referred to another provider within the practice to make sure you have A provider better suited for your needs.

* For those who may need disability paperwork, we may require a minimum of 3 visits of care and evaluation prior to filling out required paperwork. We also may recommend that patients participate in recommended intensive treatment in order to fill out disability paperwork.

Alpha Psychiatry - Appointment Request - New Patients

During this COVID-19 pandemic, we offer Telemedicine appointments.

How did you hear about us?

Patient Information

Additional Information

PLEASE NOTE: