Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Email
*
Phone
(###)
###
####
Who are you interested in working with?
*
Are you seeking in-person, telehealth visits or both?
In-person
Telehealth
Hybrid of both
Where are you located?
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I understand that I must be either located in California or willing to travel here in order to obtain treatment with Concordis for licensing reasons:
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Yes, I am located in California or willing to travel.
No, I am neither located in California, willing or able to travel. I will seek care elsewhere.
I have reviewed the fee structure and billing practices and I agree to pay the above fees if I decide to work with a provider at Concordis:
*
Yes, I have reviewed the fee list and I am willing and able to pay those fees
No, I have not reviewed the fees or am not able or willing to pay them and I will seek out a different psychiatrist
Do you have any questions regarding fees or billing? If so please ask them here:
What is causing you to seek care?
*
What are your goals for treatment?
*
Do you have any questions that will help determine if Concordis is the right fit for you?
Are you currently using any of the following medications?
I understand that the above information is not HIPAA protected
*
This is not an emergency
*
If you are experiencing a mental health emergency, please call 911 or go to the nearest emergency room.
Thank you for taking the time to fill out our form. Your information has been submitted successfully and will be reviewed by one of our providers.
Now it’s time to schedule.
Please click below to schedule your 15 minute consultation. If you don’t see a time that works for your schedule, you can email us at info.concordisbh.com
